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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <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 _ <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) JcaAr. Zuy1 U1 V` r Vr,j.t�lA t' i/' t ffleG�4 <br />Mailing Address C,?,A-t. bI U e - <br />City, St., Zip <br />Phone <br />Well Hole Owner: <br />Mailing Address, City, St., Zip <br />ACTUAL WELL LOCATION: County Crest JUTA ja <br />Property Address, City, St, Zip <br />1/4 of the 1/4, Sec. _, Twp. ❑ N. or ❑ S., Range <br />Distance from Section Lines Ft. From ❑ N. or ❑ S., <br />Subdivision Name <br />For Office Use Only <br />❑ E. or[] W., _ P.M. <br />Ft. From ❑ E. or ❑ W. Line. <br />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 13,X; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />Fasting 2, 733 04, J U Northing <br />I (we) report the existing well (hole) was plugged and sealed on the date of77for 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) Test Eoy,!!�PlJ A><uua�eu��Cl 'tcl� OIIf.CiWUt�UllMleK� <br />Tha wall was nlunaed with the following materials placed at the indicated intervals: <br />Intervals of casing removed/ripped in feet <br />Interval <br />from AQ feet toQ_ feet <br />- o6m '--IQ feet to (Q_ feet <br />from I () feet to Sup tCf`feet <br />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. <br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Please print the Signer's Name tt& Title Date <br />-1oUc.'tJ�c�t/S`t'tll/ <br />­ - I <br />It is the re ponsibility of the well owner to have the wellJhole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />