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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> 1 GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> �0312017 www.water.state.co.us and dwrpermitsontine@state.co.us --� <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 welt or MH File Number MH- 58912 <br /> Owners Well Designation- 1G Receipt Number: <br /> 2. individual/Company responsible for plugging and sealing the well: <br /> Name(s) Leo Gilbride /Agapito Associates, inc. License# Colo PE# 33324 <br /> Mailing Address 715 Horizon Drive, Ste. 340 ` 01 <br /> City, St., Zip Grand Junction, CO 81506 <br /> Phone ( 970 ) 242-4220 Email gilbride@agapito.co 1 <br /> ........... . ............ .. . ----- — _.._...._...._............... - _ <br /> 3. Well (Hole) Owner: Narne(s): RMR Aggregates, Inc. <br /> Phone: ( 720 ) 660-3279 Email rwatil6r@rmrhotdings.com <br /> .Malting Address, CiMy, St., Zip: 4601 DTC Blvd., SX. 1 <br /> 4. Well Location Address: 1001 Transfer Trai <br /> 5. GPS Well Location: County Garfield <br /> E 512.5 Northing 4382575.2 <br /> UTM []Zone 12 or El Zone 13 <br /> 6, Legal Location: _1/4 of the /4, Sec 36 , Twp 5 ❑N or S FE], Range 89 ❑ F or W❑■ 6th p,M, <br /> Distance from Section Lines Ft. From ❑ Nor S Ft. From ❑ E or W El Line. <br /> Subdivision Name Lot , Block_, Filing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on 11/12/2018 (date) for the following reason(s): <br /> 0 The well was plugged and sealed as required under Well Permit Number MH-58912 <br /> El 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 l (Multiple Confining Layer) p Laramie-Fox Hills <br /> (check one) ❑ Type II (Not Overlain by Type Ill) ❑Type II (Overlain by Type Ill ❑ 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, I <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 128 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 /> filinc nnlinp the Statp Fn*inopr rnnCiriprG the pntry of the lirpneprl rnntrartnr'r namp to ho in rmmrslianrp with Riila 17 4 <br /> ..___._.______.__-_...-_...—..--__—__-......_......... ...... . ... ... ... ._..._..... ....... ._...—...._.._-_...._.....-.....-...... _..... ....._.- .. ..._.._. -- ....... _ <br /> 11. Signature(s) Please Print the Name, Title, it License No. Date <br /> Leo J- Gilbride Leo Gilbride, VP& Principal 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 />