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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)866-3689 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 — <br /> Individual/Company responsible for Plugging and sealing the well: <br /> NAME(S) _yI u l Rrti�I lelr 1TJY.L t t L <br /> Mailing Address M� Ter A CPtttYV- DV1%V-e <br /> City,St.,Zip T G <br /> Phone <br /> Well(Hole)Owner: ++ r <br /> NAME(S) C116vujC, 11r1C, Phone <br /> Mailing Address,City,St.,Zip <br /> --7---. <br /> ACTUAL WELL LOCATION: County S 1i✓� tuvl <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 139; Units must be meters;Datum must be NAD83; Unit must be set to true north. <br /> Easting 7_ .:I,S- L Northing <br /> I (we)report the existing well(hole)was plugged and sealed on the date of _� I for the following reason(s): <br /> ❑ The well was plugged and sealed as required under Well Permit Number <br /> 0 The well was not in use and was plugged and sealed. i <br /> 5it0ther(please explain) Tes4- 1 OlN iA u :721tAu qec) tit (ALCAIA AA�Qs4� <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material Method of Placement Interval �--Z�,5 <br /> TP4 ?X>n i A u u? Alvgvt r e4g I e r Wi -�ACJ,urcw l from 1�0_feet to _feet <br /> ) `% from feet to 10 feet <br /> 4 0 i 6. Po,-6 uk, tM�x tv ` <br /> isL�, I 4-�t� ,v SlfArv�� �Nzunwtf P - try from feet to Sub eet <br /> Intervals of casing removed/ripped in feet N I C 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 /> Signatur ) — —� Please print 1the Signer's Name 8 Title Date <br /> It is the re4ponsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor i <br /> is responsible for notifying the owner of this requirement. i� <br />