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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 /> 5/2011 (303)866-3581 Fax(303)866-3589 htro://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_ M CST-I— <br /> Individual/Company responsible forlplugging and seali fn4 the well: t <br /> NAME(S) ZT0VALA -'k�r�C1r`�_ <br /> Mailing Address b c� e,.� C-P v' Vos �,e , <br /> City,St.,Zip nnL <br /> Phone ( q:FU ) <br /> Well(Hole)Owner: <br /> tl A <br /> NAME(S) o�oU (--10(XW-(USSd 11 A - i Phone ( 7 /)�nqk(,- q24� <br /> Mailing Address,City,St.,Zip - 1c <br /> ACTUAL WELL LOCATION: County SGtvk .Tttuw ' <br /> Property Address,City,St,Zip <br /> 1/4 of the—1/4,Sec.—,Twp. ❑ N.or❑S., Range E]E.or W.,—P.M. I <br /> f; <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, oizone 12❑ or zone 13 K- r�Units mustbe meters;Datum must be NAD83; Unit must beset to true north. <br /> Easting 24 3 4,5 l. 0i) Northing 419[� 7. q� <br /> I(we)report the existing well(hole)was plugged and sealed on the date of 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) T l� -ArViInc. 'Jawtpd ` �ce12 1oV' C1 <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material Meth d of Placement Interval <br /> Tpy�—?�OYIi C A I itAu u lr kJ�t.�r�Vf'AW ii ff from�5 feet to —I S feet <br /> 't M, t?�OLOA- I\o 1�_ from `� feet to _feet <br /> O 1 k w/ t v- <br /> td- C',�Wla- inu l P from I U feet to Su 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)hav read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> I <br /> Signatur s) __ Please print the Signer's Name 8 Title Date <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 />