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RPM, Inc. <br /> Form No. STATE OF COLORADO,OFFICE OF THE STATE ENGINEER For Office Use Only <br /> G 821 Centennial Bldg., 1313 Sherman St.,Denver,CO 80203 <br /> 4/2012 (303)866-3581 Fax(303)866-3589 dwrimmitsonlineastate.co.us <br /> WELL ABANDONMENT REPORT <br /> rue io report oill tg and asasng of permitted waits,rr"*wing and other holes. This form can be <br /> Ca"* W gOrmated,typed or printed in black or blue ink. Instructions and pkQ&V standards are on M RECEIVED <br /> WON Permit Number of the WON bring plugged 240323 or <br /> MH File NUMber MH-40319 Hole ID#/Nam. _ W-6 FEB 13 2014 <br /> Irldfyfdlml/ComPxlYresoonsible for Qluaafrlo and sisalino the won: WATER RESOURCES <br /> STATE ENGINEER <br /> Name(s) Transit Mix of Pueblo COLO <br /> Mailing Address 444 E Costilla St. <br /> City,SL,Zip Colorado Springs,CO 80903 <br /> Phone(vea code a no.) 7IH75-0700 Email: <br /> Well(Halal Owner: <br /> NAME(S) Transit Mix of Pueblo Phone(include area code) 719-475-0700 <br /> Mailing Address,City,St.,Zip 444 E CostlNe St,Colorado Springs,CO,80903 v <br /> 'ACTUAL W11!LOCATION: County <br /> Pueblo I <br /> Pr —ty Address,City,St.ZP <br /> €1/4 of life-m 1/4,Sec.34 ,Twp. 20 D N.or ® S.,Range 64 ID E.or ® W.. 6th P.M. <br /> Disumm from Sewon Lines 1520 Pt.from IM N.or E3 S.. 2063 Ft.from DE.or ®W.Line. <br /> Subdivision Name Lot 91odk ,FinnglUnit <br /> Optional:GPS well location Information In UTM format. You must check GPS unit for required settings as follows: <br /> Formal. be UTM, zone 1213 or zone 13 t5l; Urft must be meters;Datum must be NAD63;Unit must be set to true north. <br /> Nodde . — ----- <br /> I(we)report the existing wag(hole)was plugged and sealed on the date of for the following reason(s): <br /> O The well was plugged and seated as required under Well Permit Number <br /> ❑The well was not in use and was plugged and sealed. <br /> ®Other(pleaas eukpleln) The well was located within mining area that has been mined through. The well no longer exists. <br /> The well was plugged with the following materials placed at the indicated intervals: <br /> Amount and Type of Material Method of Placement Interval <br /> NA NA from feet to feet <br /> NA NA from feet to feet <br /> IVA NA from feet to feet <br /> Intervals of easing removed/rlpped In feet from feet to feet <br /> PAnxxt MUM 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. 1(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 If signing print name&title 71'0/1 s i f- Date(mm/ddlyyyyy) <br /> l/ V, P. S rf/e S/,}jf h►n M;x .0 <br /> 4 r K 1 L) <br /> It is the responsibility of the well owner to have the well/hole properly 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:hlhumphries2oacomcast.net <br />