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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 /> 03/2017 www.water.state.co.us and dwrpermitsonline@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 well or MH File Number MH- 58912 <br /> Owners Well Designation- iM Receipt Number: <br /> 2. individual/Company responsible for plugging and sealing the well. <br /> Name(s) Leo Gilbride /Agapito Associates, Inc. License # Colo PE# 33321 <br /> Mailing Address 715 Horizon Drive, Ste. 340 <br /> City, St., zip Grand Junction, CO, 81506 <br /> Phone ( 970 ) 242-4220 Email gilbride@agapito.co <br /> _ ....... _.- .._- <br /> 3. Well (Hole) Owner: Name(s): RMR Aggregates, Inc. `4 <br /> Phone: ( 720 } 660-3279 Email: rwagner@rmrholdings.com <br /> Mailing Address, City, St.,.Zip: 4601 DTC Blvd., Ste. 120 <br /> -- <br /> 4. Well Location Address: 1001 Transfer Trail <br /> 5. GPS Well Location: County Garfield <br /> UTM ❑Zone 12 or E Zone 13 Easting 300512.5 Northing 4382575.2 <br /> 6. Legal Location; 1!4 of the� )/4, Sec 36 , Twp $ ❑N or S >•❑, Range 89 E] E or w ❑■ , 6th P.M. <br /> Distance from Section Lines Ft. From 1-1 N or S Ft. From ❑ E or W ❑ Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. I/we report the existing we([/hole was plugged and sealed on 11/27/2018 (date) for the following reason(s): <br /> ,/❑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: ❑ Type I (One Confining Layer) ❑Type I (Multiple Confining Layer) ❑ Laramie-Fox Hills <br /> (check one) ❑ Type 11 (Not Overlain by Type 111) ❑Type II (Overlain by Type III ❑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 122 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 Welt Construction Rules,2 CCR 402 2. The filing of a document that contains <br /> false statements is a violation of section 37 91 108(i)(e),C.R.S., and is punishable by fines up to$1,000 and/or revocation of the contracting license. If <br /> filing nnlina the State rnainPar rnnwiPm the antr of tha lirancorl rnntrartnr'c name to ha in rmm�lianra with Ritter 17 4 <br /> 11. Si natures 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 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 />