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RPM,Inc. <br /> Foam No. STATE OF COLORADO,OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GUNS-09 821 Centennial Bldg.,1313 Sherman St.,Denver,CO 80203 <br /> 4/W12 (303)866-3W1 Fax(303)866-3589 dwroermitsonlineiRstate.co.us <br /> WELL ABANDONMENT REPORT <br /> use th repot Wwanp am sewvg of Pon, d weft,monitorkhp and other hops. This form can be a RECEIVED <br /> compubar generated,typed or printed in black or d n khp blue ink. Instructio and ptugg standards are on <br /> revere dole of town. <br /> Well Permit Nurtlber of the well being plugged t 240318 or <br /> MH File Nurnber MH-40321 Hole ID#/Name MW_10 FEB 13 2014 <br /> Indivldual/Comnenv responsible for and seals the well: WATER RESOURCES <br /> lt�99tCf9 STATE ENGINEER <br /> Name(s) Transit Mix of Pueblo COLO <br /> Mailing Address 444 E Costilla St. <br /> City,St,zip Colorado Springs,CO 80903 <br /> Phone(arse cods&no.) Z19475-07M Emel: <br /> Won(Hoses Owner. <br /> NAME(S) Transit Mix of Pueblo Phone(include area code) 719-475-0700 <br /> Mailing Address,City,St,zip 444 E CostiAa St,Colorado Springs,CO,80903 <br /> ACTUAL WELL LOCATION: County Pueblo <br /> Property Address,City,St,ZIP <br /> M_1/4 of Bhe_HL 19,Sea 34 .Twp. 20 0 N.or ® S.,Range 64 93 E.or ® W., Bth P.M. <br /> Dletance from Secdon Unes 2387 Ft.from ®N.or E3 S., 1672 Ft.from ®E.or ❑W.Line. <br /> Subdivision Narne Lot ,Brock ,FNingtUnit <br /> Optional:GPS well locason in*xmadw In UTM fomlat You must check GPS unit for required settings as follows: <br /> Format must be UTM, zone 12 0 or zone 13®; Units must be meters,Datum must be NAD83;Unit must be set to true north. <br /> I <br /> Fasting Northling <br /> I(we)report the existing well(hole)was plugged and sealed on the date of for the following reason(s): <br /> ❑The wall was pkigged and sealed as required under Wef Permit Number — <br /> ❑The weN was not in use and was pkigged and sealed <br /> Other(please wig n) The well was located within mining area that has been mined through. The well no longer exists. <br /> The wall was pkiggsd with the following materials placed at the indicated intervals: ----- -Y <br /> Amount and Type of Materlei 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 <br /> Intervals of casing removed/Mpped In feet from feet to feet <br /> -j <br /> Rsport Mue be signed or name entered by person who performed the well plugging work or by the well owner if this person is unknown or <br /> not reachable. I(we)have read the statements made herein,know the contents thereof,and that they are true to my(our)knowledge. <br /> Sign or enter full name tf signing print name 8 We �/�pn,S;fF Date(mm/dd/yyyyy) <br /> V.P. Sa/es/11dr►;'I Mix �4✓ <br /> Pueblo I i <br /> n'1 A/►-R- l��tti•-e.—. A�k I�►`'N� ---�_ l._7-�d!y <br /> It Is the responsibli ty of the well owner to have the well/hole property plugged and sealed. The Well Construction Contractor <br /> is responsible for notifying the owner of this requirement. <br /> RPM,Inc.,25049 E.Alder Dr.,Aurora,CO 80016 Phone:(303)854-7499 Email:hlhumphries2@comcasLnet <br />