2016-12-12_GENERAL DOCUMENTS - P2011015

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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 512011 (303)866-3581 Fax(303)866-3589 http://www.water.state.co.us WELL ABANDONMENT REPORT Use to report plugging and sealing of permitted wells,monitoring and other holes. Type or print in black or blue ink. Instructions and plugging standards are on reverse side of form. Well Permit Number of the well being plugged or MH File Number MH- Hole ID#/Name Individual/Company rresoonsiblef for plugging and sealing the well: NAME(S) nVU- vt A ^^a V1 -gtjL 1 V-a A-[UPV 62Aec-111X Mailing Address (e-kA Ce.At V- �✓��U City,St.,Zip Col Phone ( 97c) Well(Hole)Owner:i{ NAME(S) CJ tO yio 00 rS� Phone Mailing Address,City,St.,Zip 0• �K 7' p (0 ACTUAL WELL LOCATION: County 4M T' aV\ Property Address,City,St,Zip 1/4 of the 1/4,Sec._,Twp. ❑ N.or❑S.,Range ❑E.or❑W.,_P.M. Distance from Section Lines Ft.From ❑ N.or❑ S., Ft. From❑E.or❑ W.Line. Subdivision Name Lot ,Block ,Filing/Unit Optional:GPS well location information in UTM format. You must check GPS unit for required settings as follows: Format must be UTM, zone 12 ❑ or zone 13*0.4* Units must be meters;Datum must be NAD83; Unit must be set to true north. n tr ^ 1 Fasting �'��,��.�. 14 Northing 4 1 L�� 'T L - I(we)report the existing well (hole)was plugged and sealed on the date of � C)1 for the following reason(s): ❑ The well was plugged and sealed as required under Well Permit Number ❑ The well was not in use and was plugged and sealed. Other(please explain) Tee T- Onto c, ?1 :ee-) C 6,WA 0 AVA The well was plugged with the following materials placed at the indicated intervals: Amount and Type of Material Method of Placement Interval FXMt ,` 14 �ps Ul i L�AAA W 1 from �. feet to =� ��% feet �a f U „� _ - from 5 feet to�_feet tiAnwtt�' from y feet to C feet wtu(Lc.S uw�Intervals of casing removed/ripped in feet V� C� from feet to feet 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. (we)have read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. Signature(( Plea a print the Signer's Name&Title Date { It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor is responsible for notifying the owner of this requirement.