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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER i For Office Use Only GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 www.water.state.co.us and dwrpermitsontineestate.co,us 03/2017 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 1. WeII Permit Number of plugged well or MH File Number MH- 58912 Owners Well Designation- 16 Receipt Number: �_ 2. Individual/Company responsible for plugging and sealing the well. Name(s) Leo Gilbride /Agapito Associates, Inc. License# Colo PE# 333 Mailing Address 715 Horizon Drive, Ste. 340 (71 City, St., Zip Grand Junction, CO 81506 Phone ( 970 ) 242-4220 Email gi(bride@agapito.c 3. Well (Hole) Owner: Name(s): RMR Aggregates, Inc. Phone: ( 720 } 660-3279 Email rwa n`r-@rmrholdings.com Mailing Address, City, St., Zip: 4601 DTC Blvd.,, . 12 4. Well Location Address: 1001 Transfer Trai 5. GPS Well location: County Garfield UTM [-]Zone 12 or OZone 13 Easting 300512.5 Northing 4382575.2 6. Legal Location: T1/4 of the_ 1/4, Sec 36 , Twp 5 ❑N or S[E, Range 89 ❑ E or W Q 6th P.M. Distance from Section Lines Ft. From E N or S Ft. From J E or W El Line. Subdivision Name Lot , Block , Filing/Unit 7. I/we report the existing we[l/hole was plugged and sealed on 10/29/2018 (date) for the following reasons): ❑✓ The well was plugged and sealed as required under Well Permit Number MH-58912 E]The well was not in use and was plugged and sealed. ❑Other (please explain) 8. Aquifer Type: El Type I (One Confining Layer) ❑Type i (Multiple Confining Layer) ❑ Laramie-Fox Hills (check one) ❑ Type II (Not Overlain by Type III) ❑Type II (Overlain by Type III 0 Type III (alluvial) 9. Intervals of Casing Removed/Ripped: from feet to feet, from feet to feet, from feet to feet, from feet to feet, from feet to feet, from feet to feet, 10. Amount and Type of Material Method of Placement Interval Cement Shovel from 0 feet to 3 feet Cuttings Shovel from 3 feet to 150 feet from feet to feet from feet to feet ....... ._... . ._.. ....... _.. _ .. __......_ ..__ ...---- -- - ._.. . ._.... . - -- --._ .._.. _ . .... .... I 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 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 false statements is a violation of section 37 91 108(1)(e),C.R.S.,and is punishable by fines up to$1,000 and/or revocation of the contracting license. If filing nnrinp the Gtatp Fnainppr rnmorlarc tha pntru of the lirpncprl rnnrrartnr'c nArnp to ha in rmmnlianrp with Rirlp 17 d 11. Signature(s) Please Print the Name, Title, Et License No. Date Leo J. Gilbride Leo Gilbride, VP& Principal 12/20/2018 Colo PE#33329 —------ 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 in writing.