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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER I For Office Use Only <br /> GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303,866.3581 <br /> 03/2017 www.water.state.co.us and dwrpermitsontinec state.co.us- <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and seating 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- I Receipt Number. <br /> 2. Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Leo Gitbride /Agapito Associates, Inc. License # <br /> NO <br /> Mailing Address 715 Horizon Drive, Ste. 340 011 <br /> City, St., Zip Grand Junction, CO 81506 <br /> Phone ( 970 ) 242-4220 Email gilbride@agapito.c <br /> 3. Well (Hole) Owner: Name(s): RMR Aggregates, Inc. <br /> Phone: ( 720 ) 660-3279 Email rwa r@rmrholdings.com <br /> Mailing Address, City, St., Zi : 4601 DTC Blvd., 120 <br /> .............- Yr P xS_ —------- - ._.._T, ..._......... _............. <br /> 4. Well Location Address: 1001 Transfer Trail <br /> 5. GPS Well Location: County Garfield <br /> UTM ❑Zone 12 or QZone 13 E 3 512.5 Northing 4382575.2 <br /> 6. Legal Location: —1/4 of the 14, Sec 36 , Twp 5 ❑N or S[j], Range 84 ❑ E or W 0 6th P.M. <br /> Distance from Section Line Ft. From LI N or S El Ft. From E or W ❑ Line. <br /> Subdivision Name Lot , Block Filing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on 10/31/2018 (date) for the following reason(s): <br /> 7 The well was plugged and seated 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: E2 Type I (One Confining Layer) 13 Type I (Multiple Confining Layer) ❑ Laramie-Fox Hills <br /> (check one) 0 Type II (Not Overlain by Type i1I) ❑Type II (Overlain by Type III (3 Type III (alluvia() <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 /> Cement Shovel from 0 feet to 3 feet <br /> Cuttiros Shovel from 3 feet to 137 feet <br /> from feet to feet <br /> from feet to feet <br /> - --...._......... ..... . .... ...... .... ..................... ... .............- -- - ._......... .......- - .-_...... .....-------. .......... ....-.- .. .......__.. <br /> I have read the statements made herein and know the contents thereof,and they are tare to my knowledge. This document is signed(or name entered <br /> if filing online)and certified in accordance with Rute 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 91 108(1)(e),C.R.S.,and is punishable by fines up to$1,000 and/or revocation of the contracting license. If <br /> filina nn[inp the State Fnoinns+r rnnririPrt the Pntry of rhP lirPniPri rnntrartnr'c names M hio in rmmnlianra with POP 17 4 <br /> 11. Signature(s) Please Print the Name, Title, Et License No. Date <br /> Leo J. Gilbride Leo Gilbride, VP& Principal 12/20/2018 <br /> Colo PE#33329 <br /> - ......._............ ..... .... .. . . ............ .. - -..._.., ............_..._......... ... _..�.. .. . ...... ......._........ <br /> It is the responsibility of the well owner to have the well/ properly plugged and sealed. The Well Construction Contractor is <br /> responsible for notifying the owner of this requirement in writing. <br />