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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 1313 Sherman St., Boom 821, Denver, CO 80203 303.866.3581 <br /> 0312017 www.water.state.co.us and dwrpermitsonlinegstate.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 well or MH File Number MH- 58912 <br /> Owners Wet( Designation- 1 K Receipt Number: Ak <br /> 2. Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Leo Gilbride /Agapito Associates, inc. License Colo PEfI 333 � <br /> Mailing Address 715 Horizon Drive, Ste. 340of <br /> City, St., Zip Grand Junction, CO 81506 <br /> Phone { 970 242-4220 Email gilbride@agapito.co}n <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 OTC Blvd., Ste. 120 <br /> 4. Well Location Address: 1001 Transfer Trail <br /> 5. GPS Well Location: County Garfield <br /> UTM []Zone 12 or 0 Zone 13 East" 300512.5 Northing 4382575.2 <br /> 6. Legal Location: _1/4 of the tf%/4 Sec 36 , Twp 5 N or S Q, Range 89 ❑ E or W 6th P.M. <br /> Distance from Section Lines NftJFt. From 12 N or S E Ft. From —0 E or W L.L Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on 11/22/2018 (date) for the following reason(s): <br /> QV The well was plugged and sealed 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: p Type I (One Confining Layer) p Type I (Multiple Confining Layer) [1 Laramie-Fox Hills <br /> (check one) ❑ Type 11 (Not Overlain by Type 111) 0 Type II (Overlain by Type Ili ❑ Type Ill (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 125 feet <br /> from feet to feet <br /> from feet to feet <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 nnlino the-C'.Wp Fnaine-pr rnnciriprc the Pntry of the lirancprl rnntrartnr'c name to hp in rmmMfianra with Riilo 17 d <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 /> It is the responsibility of the welt 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 />