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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 Bidg.,1313 Sherman St.,Denver,CO 80203 <br /> 412012 (303)888-3681 Fax(303)866-358g dwroermitsoniine0state.cp.us <br /> WELL ABANDONMENT REPORT <br /> Use to repot plugging and seeing of pwmlaed web,monlior"and other holes. This form can be <br /> computer genereiad,typed or pdrhhd in Weak or blue khk Instructions and plugging standards are on <br /> averse side of tam. JUL L 1 2014 <br /> ( Well Permit Number of the wetl being paged 240326 or <br /> i MH File Number MH- Hole ID*!Name MW4 <br /> IndividuaUComaarw resoaisible for dluaoinc and"na the well: -� <br /> Names) Transit Mix of Pueblo <br /> Mailing Address 444 E Costilla St. <br /> city,St.,Zip Colorado Springs,CO 80903 <br /> Phone(area code 3 no.)719-475-0700 Email. <br /> Wall fd,ole),Owner — -- — <br /> NAME(S)Transit Mix of Pueblo Phone(include area code)719-476-0700 <br /> Mailing Address,City,St.,Zip 444 E Costtlls St.Colorado Springs,CO WW3 <br /> ACTUAL WELL LOCATION; County Pueblo _ <br /> Property Address,City.St.Zip <br /> y _1m of ft_W im,Sec. 34 ,Twp. 20 I-7 N.or FJ S.,Range 64 0 E.or ® W.. 6 P.M. <br /> Distance from Section Lines 1596 Ft.from N.or C S, 80 Ft.tram ❑E,or ff)W.Line. <br /> Subdivision Name Lot ,Block ,Fil ft/Unit <br /> Optional:GPS wail location information in UTM format. You must check GPS unit for required settings as follows: <br /> Format must be UTM, zone 12 M or zone 13 rl; Units must be meters;Datum must be NAD83,-Unit must be set to true north. <br /> Eastkop Northbtg <br /> I(we)report t»existing well(tole)was plugged and seated on the date of for the following reasah(s): <br /> ❑The wen was plugged and seebd as regt4ned under Wag Permit Number <br /> 0 The well was not in use and was pkugged and sealed. <br /> ®Other Wesse explain) The well was located within a mining area that has_been maned through. The wail no longer exists. <br /> The wen 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 bet <br /> NA NA from feet to fast ({ <br /> NA NA from feet to feet <br /> Intervals of casing removed/dipped in feet from feet to feet <br /> Report ajW be signed or name entered by person who performed the wen 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 contsrts thereof,and that they are true to my(our)knowledge. <br /> Sign or enter hull name If signing pnnt mans 8 title i Dab(rmmldd/yyyyy) <br /> A.cf2 <br /> V.p, Svlesl 4dtnih a`1- lt-I��iY <br /> it is the responsibility of the well owner to have the well/Ws properly plugged and seated. 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(a)comcast.net <br />