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.y <br /> RPM,Inc. <br /> Form No. STATE OF COLORADO,OFFICE OF THE STATE ENGINEER For Office Use Only - - - <br /> OWS-09 821 Centennial Bldg., 1313 Sherman St.,Denver,CO 80203 <br /> 4t2012 (303)888-3581 Fax(303)886-3588 roermi(sonline0state.co us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted wells,monitoring and other holes. This form can be <br /> computer generated,typed or printed in black or blue ink. Instructions and plugging standards are on <br /> reverse side of form. ' <br /> Well Permit Number of the well being plugged 240327 or !"JL _ 203 <br /> MH File Number MH- Hole ID*111Name MW-2 <br /> Individual/Company responsible for oluaaina and sealing the well: <br /> j Name(s) Transit Mix of Pueblo <br /> Mailing Address 444 E Costlila St. <br /> City,St.,Zip Colorado Springs,CO 80903 <br /> Phone(area code&no.)719-475-0700 Email: <br /> Well(Fiol¢I Owner <br /> NAME(S) Transit Mix of Pueblo Phone(induce area code) 719-475-0700 j <br /> Mailing Address,City,St.,Zip 444 E Costilla St.Colorado Springs CO 80803 <br /> ACTUAL WELL LOCATION: County Pueblo <br /> Property Address,City.St,ZIP <br /> SW 114 of the_M 1/4,Sec. 34 ,Twp. 20 n N.or El S-,Range 84 G E.or ® W., 8 PJA <br /> Distance from Section lines 2209 Ft.from 13"'jc N.or C S., 98 Ft.from [JE.or xM 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 n or zone 13 f 9: Units must be meters;Datum must be NAD83;Unit must be set to true north. <br /> EA"ng NOrthln9 <br /> 1(vmrs)report the euosbng 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 /> 0 The well was not in use and was plugged and sealed. <br /> ®Ottw(please explain) The well was located within a 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 /> NA NA from feet to feet <br /> 1 Intervals of casing removedlripped In feet from feet to feet <br /> Report must 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 I If signing print name&title Date(mmldd/yyyyy) <br /> r-k K 1 ivi <br /> ''let V. P. <br /> it is the responsibility of the well owner to have the weWtiole 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:h1humphries2Ca comcast.net <br />