2016-12-12_GENERAL DOCUMENTS - P2011015

• Permit No: P2011015
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 12/12/2016
• Doc Name: Correspondence
• From: Colorado Goldfields Inc.
• To: DRMS
• Email Name: LJW
• Email Name: GRM
• Email Name: AJW
• Media Type: D
• Archive: No

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
5/2011
[phone] Fax [phone] htip://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 responsible for plugging and sealing the well:
1
I IC- L-04C
NAME(S) lri�nr��lnuy\ !­Y.AaE
^IPtiT
Mailing Address (o?�
City, St., Zip L)UV"Qut C) C n
Phone ( L) --aSR - 5095
Well (Hole) Owner:
}}
NAME(S) C-olnvU(lci Phone
1
Mailing Address, City, St., Zip t� gV 7�0 , S ! �)fV-6 l C C, R1
Q'0-0
ACTUAL WELL LOCATION: County &vt TrA,,n
Property Address, City, St, Zip
1/4 of the_ 114, 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 11 or zone 13 A; Units must be meters; Datum must be NAD83; Unit must be set to true north.
Easting 2'434 9��o� 9 Northing-��SUZs'T
- -- - - - -
— --pp
— _ --
(we) report the existing well (hole) was plugged and sealed on the date of Ci 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.
'ErOther (please explain) f U + "C, V (. CX,1Vd '
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type of Material Method of Placement Interval
t l ;�� (9•,7�u% ` from 62Q�'L feet to feet
1�' V,
eA,iAu� iyk(Ve' rC Guciv�Gc/r�_W4�-tPut.' c 1in-�t�1P from— 15 feet to C', feet
b 1 . �a { VA,t'x 0
_ from �—
io•�OvVASuw•feet to , feet
•mil) tE] tF•Pl• rx,r. W t.utn- o E.-
{t✓
y
Intervals of casing removed/ripped in feet 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. I
(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
Signature(s)
Please print the Signer's Name & Title
Date
T��,-�►� ���rr-ale � �
� _
Ell. i
,
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.