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Form No. <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />For Office Use Only <br />GWS-09 <br />821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />5/2011 <br />(303) 866-3581 Fax (303) 866-3589 htW://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 k AL I - <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) S �nc�y� �ta'�I lvuu L�Py GcoteGt <br />Mailing Address r �i e- l� C A } r,r- 0✓ U e <br />n <br />City, St., Zip N V cwAuC-� , C <br />Phone (-YQ) <br />Well (Hole) Owner: <br />ij r <br />NAME(S) l G1c�y\, C C:� Phone (� ) ` �'z -rS <br />�Q <br />Mailing Address, City, St., Zip c', <br />' <br />ACTUAL WELL LOCATION: County &tA I rirj iA <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 UpTM, zone 12 E] or zone 13�. Units must be meters; Datum must be NAD83: Unit must beset to true north. <br />Fasting ��-� 5. 7 J Northing 4`'6�-, <br />I (we) report the existing well (hole) was plugged and sealed on the date of , 5 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 and sealed. <br />!plugged <br />( <br />other(pleaseexplain) Tp t 1 r ALA -i-LI 0V\0 S I P � •-toV AGt,[ MWtPtni- <br />4C) , <br />The well was plugged with the following materials placed at the Indicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />PSt tic) ^,yV u (1AX 6uo`ylu Cau Ufy W 41(;v.,uA from feet to I feet <br />I' v c) r)W^, ct:u,vl- from` 1 feet to feet <br />Vl jJ2Yw� S-uy, Jdi w�- IL. from_ feet to 'AI A feet <br />• <br />.l <br />Intervals of casing removed/ripped in feet 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 />Signature(s), <br />Please print the Signer's Name 8 Title <br />Date <br />It is the re§ponsibility 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 />