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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 43/2017 www.water.state.co.us and dwrpermitsontineCstate.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- 1L Receipt Number. .._..._.....__..._... ...... .... 2, Individual/Company responsible for plugging and seating the well: Name(s) Leo Gilbride /Agapito Associates, Inc. License# Coto PE#333 Mailing Address 715 Horizon Drive, Ste. 340 ` City, St., Zip Grand Junction, CO 81506 Phone ( 970 ) -242-4220 -__--Email gflbrjde@agapito.cVkNX 3. Well (Hole)Owner: Name(s): RMR Aggregates, Inc. ION Phone: ( 770 ) 660-3279 Email rwas @rmrholdings.com Mailing Address, City, St., Zip: 4601 DTC Blvd.,, . 12 ' 4. Well Location Address: 1001 Transfer Trai 5. GPS Well Location: County Garfield UTM ❑Zone 12 or QZone 13 Ea 512.5 Northing 4382575.2 6. Legal Location: —114 of the /4, Sec 36 , Twp 5 ❑N or S 0, Range 89 ❑ E or W 6th p.M, Distance from Section Lines Ft. From E N or S ❑ , Ft. From E or W ia Line. Subdivision Name Lot , Block , Filing/Unit 7. I/we report the existing welt/hole was plugged and sealed on 11/26/2018 (date) for the following reason(s): 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) p Laramie-Fox Hills (check one) ❑ Type II (Not Overlain by Type 111) 0 Type 11 (Overlain by Type Ill ❑Type III (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 131 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$1,000 and/or revocation of the contracting license. If filing nnlina tha rt»ta FnoinPar rnncirtPra the pntne of the liconcPri rnntmrtnr'c names to hP in rmmnlianra with Rida V A 11. Signature(s) Please Print the Name, Title, Ft License No. Date Leo J. Gilbride Leo Gilbride, VP& Principal 12/20/2018 Colo PE#33329 _.......... • It is the responsibility of the well owner to have the well/dole properly plugged and sealed. The Well Construction Contractor is responsible for notifying the owner of this requirement in writing.