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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br /> 5/20 0 (303)866-3581 Fax(303)866-3589 httn://www.water.state.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells,monitoring and other holes. Type or <br /> print in black or blue ink. Instructions and plugging standards are on reverse side of form. <br /> Well Permit Number of the well being plugged or <br /> MH File Number MH- Hole ID#/Name - <br /> Individual/Company responsible for plugging and sealing the well: <br /> NAME(S) ,- <br /> Mailing Address Pr.�, CleAA-CV- bti^i U e— <br /> City,St.,Zip <br /> Phone <br /> Well(Hole)Owner:NAME(S) Cole)Vx ) n4 o '223J � j <br /> Phone <br /> Mailing Address,City,St.,Zip R o Rn�( ?90 t S Jut.U'" Cn �'1 4'4D <br /> ACTUAL WELL LOCATION: County SIA <br /> Property Address,City,St,Zip <br /> 1/4 of the 1/4,Sec._,Twp. ❑ N.or❑S., Range ❑E.or❑W.,_P.M. <br /> Distance from Section Lines Ft.From ❑ N.or❑ S., Ft. From❑E.or❑ W.Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> Optional:GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br /> Format must be UTM, zone 12❑ or zone 13�1 Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Easting Northing i <br /> I(we)report the existing well(hole)was plugged and sealed on the date of (T for the following reason(s): <br /> ❑ The well was plugged and sealed as required under Well Permit Number <br /> ❑The well was not in use and was plugged and sealed. <br /> ,Other(please explain) 1 �t <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material Method of Placement Interval <br /> tA/i-�(A 3A4W from 3 feet to �-Z� feet <br /> L II i <br /> G V Ci t i tuV\ -ko e, from zU feet to feet <br /> 20I <br /> �Dr,tclin-Ly t '� from_�_feet to 4.✓`�(C�eet <br /> Intervals of casing removed/ripped in feet from feet to feet <br /> Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. I <br /> (we)have read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> i <br /> Signatur ) A ^- Please print the Signer's Name&Title Date <br /> ZQAtI- !A <br /> It is the r sponsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br /> is responsible for notifying the owner of this requirement. - <br />