Laserfiche WebLink
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 /> 5/2011 (303)866-3581 Fax (303)866-3589 htip://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 we II: <br /> NAME I S) ryu,,-t. yAyk YIX-Ley- l l zejr Gwo-[= <br /> Mailing Address M-r1 t vcln cewLrv' <br /> City,St.,Zip <br /> Phone <br /> Well(Hole)Owner: A <br /> NAME(S) C 06-1Ibj- (1n1U'H21trS!5 - Ma-- Phone (3iI�) <br /> S' <br /> Mailing Address,City,St.,Zip t� tJ �V ��� r �\^1- :A �� ?t 4-X _ — _- <br /> ACTUAL WELL LOCATION: County. Se A <br /> Property Address,City,St,Zip 1 <br /> a <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 El or zone 13 X Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Easting M4 9u)(, �9 Northing �-1 SSOZS.3� ---©© - -- -------- -- h <br /> I(we)report the existing well(hole)was plugged and sealed on the date of V t� 1 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 /> r <br /> Other(please explain) f to + 'v <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 /> TPS+- V,ignu Cni jey 6�uv f vtu au a Py1 iu+-L�\&;(,A from XL feet to feet <br /> oA to-, I wtnerr PC} CGuu vGGc�T� Uti�-tPu'c,` cY7u�In— b�(' from= IS' feet to�feet <br /> b 1 . '� ,A VA',x ' ��- t r <br /> _'OIL- ')-P,A�,'j � wl w,.{.r✓ -ko�ovw�Suw� �[j����lnolfr from�_feetto �'t�+ feet <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 /> Signature(s) Please print the Signer's Name&Title Date <br /> , <br /> t —To iku L U A 3 ale t/ ' F- . --- <br /> It is the responsibility 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 />