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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 <br /> I 4i20` 12 I (303)886-3581 Fax(303)886-3589 dwroermitsonline*.state.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells.monNorinp and other holes, This form can be <br /> canputw generated,typed of pnntea in black or blue ink, Instructions and plugging standards are on <br /> reveres dde of form. <br /> Well Pormlt Number of tM well being plugged 240324 or JUL, 11 2014 <br /> MH File Number MH- Hole ID fltlName MW-5 <br /> IndividuaVComuany responsible for plugging and sealing the well: <br /> Name(s) Transit Mix of Pueblo <br /> Mailing Address 444 E Costilla St. 1 <br /> City.St.,Zip Colorado Springs,CO 80903 <br /> Phone(area code&no_)719-475-0700 Email: <br /> Well(HOW)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 /> ACTUAL WELL LOCATION: County Pueblo <br /> Property Address,City,St,ZIP <br /> _1/4 of the im.Sec 34 Twp 20 1"1 N.or E S,Range 64 © E.or W., 8 P M. <br /> { Distance from Section Linea 2013 FL from n N.of r S, 977 Ft.from ❑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 f` or zone 13 171; Units must be meters;Datum must be NAD83:Unit must be set to true north. <br /> East ing Northing <br /> I(we)report the wdsting 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 ano was plugged and sealed. <br /> Other(please explain) The well was located within a Spina area that has been mined through. The well no longer exists. <br /> The well was plugged with the following materials placed at the indicelDd 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 /> I( <br /> NA NA from feet to feet ` <br /> Intervals of casing removedfripped in feet from feet to feet r <br /> Report must be signed or name entered by person who perbmred the well plugging work or by the well owner if this person is unknown or <br /> not reachable. I(we)have read the stalernents made heroin,know the contents thereof,and that they are true to my(our)knowledge <br /> Sign or enter full name 1 if signing print name&tite Date(mmlddlyyyyy) <br /> It is the responsibility of the well owner to have the well/hole property plugged and smled. 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@comcast.net <br />