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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 03/2017 www.water.state.co.us and dwrvermitsonlinegstate.co.us 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. Well Permit Number of plugged well or MH File Number MH- 58912 Owners Well Designation- 1J Receipt Number: 2. Individual/Company responsible for plugging and sealing the well: Names) Leo Gilbride /Agapito Associates, Inc. License# Colo PE# 333 Mailing Address 715 Horizon Drive, Ste. 340 City, St., Zip Grand Junction, CO 91506 Phone ( 970 ) 242-4220 Email gilbride@agapito,co i 3. Well (Hole) Owner: Name(s): RMR Aggregates, Inc._ Phone: ( 720 } 660-3279 Emailrmrholdings.com Mailing Address, City, St., Zip: 4601 DTC Blvd,,Sft. 120 4. Well Location Address: 1001 Transfer Trai 5. GPS Well Location: County Garfield UTM []Zone 12 or 0 Zone 13 Eas ' 300512.5 Northing 4382575.2 6. Legal Location: _1/4 of the /4, Sec 36 , Twp 5 ❑N or S T, Range 89 ❑E or W Q 6th P.M. Distance from Section Lines '' Ft. From El N or S ❑ Ft. From ❑ E or W❑_ Line. Subdivision Name Lot , Block , Filing/Unit 7. I/we report the existing well/hole was plugged and sealed on 11/20/2018 (date) for the following reason(s): Q The well was plugged and sealed as required under Well Permit Number MH-58912 The well was not in use and was plugged and sealed. ❑Other (please explain) 8. Aquifer Type: ❑ Type I (One Confining Layer) ❑Type i (Multiple Confining Layer) ❑ Laramie-Fox Hills (check one) ❑ Type 11 (Not Overlain by Type III) ❑ Type iI (Overlain by Type ill ❑ Type Ili (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 124 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 S1,000 and/or revocation of the contracting license. If filing nnlinp the rtatp FnainpPr rnnciAprc the pntry of tha lirancarf rnntrartnr'c ramp to ha in rmmniianrp with Ritla 17 d 11. Signature(s) Please Print the Name, Title, Ft License No. Date Leo J. Gilbride Leo Gilbride, VP& Principal 1 212 0/2 0 1 8 Colo PE#33329 It is the responsibility of the well owner to have the well/ properly plugged and seated. The Well Construction Contractor is responsible for notifying the owner of this requirement in writing.