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r Form No ; STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 ' 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> www.water.state.co.us and d�ermitsonline@state.co.us <br /> 03/2017 <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells, monitoring and other holes. Type <br /> or print in black or blue ink. Instructions and plugging standards are on reverse side <br /> 1. Well Permit Number of plugged well or MH File Number MH- 58912 <br /> Owners Well Designation- 1A Receipt Number: <br /> 2 Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Leo Gilbride /Agapito Associates, Inc. License #! Colo PE11 33329 <br /> Mailing Address 715 Horizon Drive, Ste. 340 <br /> City, St., Zip Grand Junction, CO 81506 <br /> j Phone { 970 } 242-4220 Email gilbride@agapito.co <br /> 3. Well (Hole) Owner: Name(s): RMR Aggregates, Inc. <br /> I Phone: ( 720 ) 660-3279 Email rwa bi-mrholdings.com <br /> Mailing Address, City,.St.,_Zip: 4601 OTC Blvd., Ste. 120 <br /> 4. Well Location Address: 1001 Transfer Trail <br /> 5. GPS Well Location: County Garfield <br /> UTM ❑Zone 12 or Q Zone 13 Easting 300512.5 Northing 4382575.2 <br /> 6. Legal Location: �1/4 of the— 1l4, Sec 36 , Twp 5 ❑N or S[E, Range S9 ❑ E or W 6th P.M. <br /> Distance from Section Lines Ft. From U1 N or S Ft. From _0 E or W ❑ Line. <br /> Subdivision Name Lot , Block , Fiiing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on 10/25/2018 (date) for the following reason(s): <br /> 0 The well was plugged and sealed as required under Well Permit Number MH-58912 <br /> ❑The well was not in use and was plugged and sealed. <br /> ❑Other (please explain) <br /> 8. Aquifer Type: ❑ Type I (One Confining Layer) [:]Type I (Multiple Confining Layer) ❑ Laramie-Fox Hills <br /> (check one) ❑ Type II (Not Overlain by Type 111) ❑Type II (Overlain by Type III ❑ Type III (alluvial) <br /> 9. Intervals of Casing Removed/Ripped: <br /> from feet to feet, from feet to feet, from feet to feet, <br /> from feet to feet, from feet to feet, from feet to feet, <br /> 10. Amount and Type of Material Method of Placement Interval <br /> i <br /> Cement Shovel from 0 feet to 3 feet <br /> Cuttings Shovel from 3 feet to 173 feet <br /> from feet to feet <br /> from feet to feet <br /> ............ <br /> have read the statements made herein and know the contents thereof, and they are true to my knowledge. This document is signed (or name entered <br /> if filing online) and certified in accordance with Rule 17.4 of the water Well Construction Rules,2 CCR 402 2. The filing of a document that contains <br /> false statements is a violation of section 37 9i 108(1)(e),C.R.S.,and is punishable by fines up to$1,000 and/or revocation of the contracting license. If <br /> filino nnlina tha Staff fnainawr rnncirlarc tha antry of tha lirancPrf rnntrxrrnr'c Hama to ha in rmmnhnnra with Rhin 17 4 <br /> 11. Signature(s) Please Print the Name, Title, Et License No. Date <br /> Leo Gilbride, VP & Prinicpal 12/20/2018 <br /> Colo PE#33329 <br /> It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor is <br /> responsible for notifying the owner of this requirement in writing. <br />