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orm No STATE OF COLORADO, OFFICE OF THE STATE ENGlN-E-ER For Office Use Only <br /> GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> www.water.state.co.us and dwrpermitsonline@state.co.us <br /> 03/2017 WELL ABANDONMENT REPORT <br /> Use to report plugging and seating 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. WeIl Permit Number of plugged well or MH File Number MH- 58912 <br /> Owners Well Designation- 1 N Receipt Number: <br /> 2. individual/Company responsible for plugging and sealing the well: <br /> Names) Leo Gilbride /Agapito Associates, Inc. License# Colo PE# 33329, <br /> Mailing Address 715 Horizon Drive, Ste. 340 <br /> City, St., Zip Grand Junction, CO 81506 <br /> Phone { 970 ) 242-4220 Email ashaffer@agapito.com <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 DTC Blvd., Ste. 120 <br /> 4. Well Location Address: 1001 Transfer Trait <br /> 5. GPS Well Location: County Garfield <br /> UTM ❑Zone 12 or 0 Zone 13 Easting 300512.5 Northing 4382575.2 <br /> 6. Legal Location: 1/4 of the /4, Sec 36 , Twp 5 ❑N or S❑■ , Range 89 ❑ E or W Q 6th p M <br /> Distance from Section Lines Ft. From N or S Ja , Ft. From -0 E or W ❑ Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on 11/29/2018 (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 Ili ❑ Type Ill (alluvial) <br /> . _ <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 Shove! from 0 feet to 3 feet <br /> Cuttings Shovel from 3 feet to 124 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(i)(e), C.R.s., and is punishable by fines up to$1,000 and/or revocation of the contracting license. If <br /> filing nnlinP the Stara Fnainaar rnnwiarc the Pntry of the lirancprl rnntrartnr'r,name to hP in rmmnlianrP with Riilp 17 4 <br /> 11. Signature(s) Please Print the Name Title l3 License No. Date <br /> Leo J. Gilbride Leo Gilbride, VP& Principal 12120/2018 <br /> Colo PE# 33329 <br /> - _ . .....-- _....-... -- - <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 />