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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 http://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 KIM LT--Z <br /> Individual/Comoanv responsible for plugging and sealing the well: <br /> NAME(S) `UTAuZ'v�tll/� �i't21( , I UY1cAPJ' �x'�� t'G <br /> Mailing Address �04c� tec. l Pt�7t✓' <br /> City,St.,zip -DutnAW C2 CCU (3o <br /> Phone <br /> Well(Hole)Owner: 1 --���� <br /> NAME(S) Colnvr�c�F, <br /> T <br /> ��� ��c'e�tJ� Phone ( IV ) 94-fo 3 <br /> Mailing Address,City,St.,Zip O _F�e,,,c �r�t��1X5yy C 0 P 147 C) <br /> ACTUAL WELL LOCATION: County _I•k.tV\ <br /> Property Address,City, St,Zip <br /> 1/4 of the 1/4,Sec._,Twp. ❑ N.or❑S.,Range ❑E. or E]W.,_P.M. <br /> Distance from Section Lines Ft.From E] 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 13A* Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> , <br /> Easting 2-� (r.o r Northing <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) ^I �! LA A u 14401'e t� SPG,1Ql) ice✓ CA�(�tCbvlWt2c <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material I Method of Placement Interval <br /> TP R�t0SA C."er) I.LV, %4 AuuP �irTl117J1♦It:IW ( from _feet to kr EQ feet <br /> _ 11 <br /> Wt(vlu� iu�0ov`-t2r xuu uA L �I'u �11�a/1ut�Vfrom feet to feet <br /> -iU -c.✓uA Aluvvu -tytunwf't P to C, from C� feet to feet <br /> Intervals of casing removed/ripped in feet V �ct 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 /> SignatLq Please print p the Signer's <br /> Name&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 />