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RPM,Inc. <br /> Form No. ' STATE OF COLORADO,OFFICE OF THE STATE ENGINEER For Office Use Only ' <br /> GWS-09 821 Centennial Bldg., 1313 Sherman St.,Denver,CO 80203 j <br /> 412012 (303)866-3581 Fax(303)Wri-3589 dwERermitsonfineostate.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and searing of permitted webs.mor4or*V and other hobs. This form can t>err- <br /> i computer generated typed or printed in Wade or blue ink. Instructions and plugging standards are on <br /> I reverse side of form. <br /> t Well Penult Number of the well being plugged 240322 -- -- or JUL j j 2014 <br /> MH File Number MH- Hole ID#/Name MW-7 <br /> lndWuaVCompanv responsible for plugging and sealing the well: -- <br /> Name(s) Transit 111 Of Pueblo <br /> Mailing Address 444 E Costilla St. 1 <br /> City,St,Zip Colorado Springs,CO 80903 <br /> Phone(area code a no.)719-475-0700 Email <br /> Well(Hole)Owner: <br /> NAME(S) Transit Mix of Pueblo Phone(include area code)719-475-0700 <br /> Mailing Address,City,St.,Zip 444 E Costilla St.Colorado Springs,CO 80903 <br /> - --. ___------ ------## <br /> ACTUAL WELL LOCATION. County Pueblo <br /> Property Address,City, St,Zip <br /> ±ff_114 of the_M 114,Sec. 34 Twp. 20 1'1 N.or I] S.,Range 64 C E.or ll W., 6 P M <br /> Distance from Section Unes 1309 Ft.from IM N.or S., 2545 Ft from <br /> C ❑E or ®W.Line. <br /> Subdivision Name Lot .Block ,Filing/Unit <br /> Optional:GPS well location information in UTM format You must check GPS unit for required settings as follows' <br /> Format must be UTM, zone 12 r or zone 13 r]; Units must be meters;Datum must be NAD83,Unit must be set to true north. <br /> Existing Northing <br /> l <br /> 1(we)report the existing well(hole)was plugged and sealed on the date of for the following reason(s). <br /> ❑The well was plugged and sealed as required under Well Permit Number <br /> ❑The well was not in use and was plugged and sealed. <br /> m Other(please explain) The well was located was located w�htn a mining area that has been mined The well no longer mining area that has been min through. The well no longer exists. <br /> 1 <br /> I The wel was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Matertal Method of Placement Interval <br /> NA NA from feet to feet <br /> NA NA from feet to feet <br /> NA NA from feet to feet i <br /> Intervals of casing removeWripped in feet from feet to feet <br /> Report P iga be awned or rtanre entered by person who performed the well plugging work or by the well owner if tins person is unknown or <br /> not reachable. 1(we)how read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> i <br /> Sign or enter full name If signing print name 8 title Date(mm/dd/yyyyy) r <br /> /h arlt K/uA/C <br /> akk V.P.P. Salea/ ,4d�� i d 1-rr-Aal y <br /> It is the responsibility of the well owner to have the welt/hole properly plugged and sealed The Well Construction Contractor <br /> I is responsible for notifying the owner of this requirement. <br /> RPM,Inc.,25049 E.Alder Dr.,Aurora,CO8M16 Phone:(303)854-7499 Email:hlhuinphries2 a comcast.net <br />