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 5/2011 (303) 866-3581 Fax (303) 866-3589 htW://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 b Individual/Companyresponsible for plugoina and sealing the well: NAME(S) I V u —L WA Mailing Address 6 ic� City, St., Zip 1)av'uvt U C', Phone Well (Hole) Owner: tt 11 NAME(S) CCAV-u60 Phone Mailing Address, City, St., Zip P L '`zX ACTUAL WELL LOCATION: County �V✓l -..ii. V, 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 0 or zone 13X; Units must be meters; Datum must be NAD83; Unit must beset to true north. Easting Northing1 (we) report the existing well (hole) was plugged and sealed on the date of 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) . l The well was plugged with the following materials placed at the indicated intervals: Amount and Type of Material Method of Placement Interval T � P J' iN J u'U VL 1 from R feet to C�'— feet j� {ul1U j 1 !ka '�T unrPvuiYPc! i :�rtAin— Vk,�_ from I L feet to v' feet wv{�✓-�, 1G,tivi siovoi, from feet to feet Intervals of casing removed/ripped in feet from feet to feet Report Yr t s 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. i Signature(s) Please print the Name Date ,Signer's y&' Title 1 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.