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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 dwrpermitsonlinecstate.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- 1 D Receipt Number: <br /> 2. Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Leo Gilbride / Agapito Associates, Inc. License # Colo PEA 33329 <br /> Mailing Address 715 Horizon Drive, Ste. 340 <br /> City, St., Zip Grand Junction, CO 81506 <br /> Phone ( 970 ) 242-4220 Email gilbride@agapito.com <br /> 3. Well (Hole) Owner: Name(s): RMR Aggregates, Inc. <br /> Phone: ( 720 ) 660-3279 Email, rwagner@rmrholdings.com <br /> Mailing Address, City, St., Zip: 4601 DTC Blvd., Ste. 120 <br /> 4. Well Location Address: 1001 Transfer Trail <br /> 5. GPS Well Location: County Garfield <br /> UTM Zone 12 or QZone 13 Easting 300512.5 Northing 4382575.2 <br /> 6. Legal Location: _1/4 of the _,.-_1/4, Sec 36 , Twp S ❑N or S 0, Range 89 ❑ E or W Q 6th P.M. <br /> Distance from Section Lines Ft. From N or S Ft. From ❑ E or W a Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. I/we report the existing welt/hole was plugged and sealed on 11/02/2018 (date) for the following reason(s): <br /> 0 The well was plugged and sealed as required under Well Permit Number MH-58917 <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 III) ❑Type II (Overlain by Type 111 ❑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 /> Cement Shovel from 0 feet to 3 feet <br /> Cuttings Shovel from 3 feet to 138 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 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 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 /> filino nniino tho State FnoinPPr rnn6riPrc the Pntry of the iirRnCPri rnntrartnrlC wqm%M hP in rnrnnlianrP with RIIIP 17 A <br /> _ -.__.._._._ -----...._... ..... . ... _,. ........_. .... .. -.-.._..... ...._.. .. ...........-- ..__._..__... ....._. _ _.... <br /> 11. Signature(s) Please Print the Name, Title, Et License No. Date <br /> Leo J. Gilbride Leo Gilbride,Agapito Associates, Inc. 12/20/2018 <br /> Colo PE#33329 <br /> It is the responsibility of the well owner to have the well/hole properly plugged and seated. The Welt Construction Contractor is <br /> responsible for notifying the owner of this requirement in writing. <br />