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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 /> 4l2012 (303)866-3581 Fax(303)W6-3589 dwirpermitsonlineAstate.co.us <br /> WELL ABANDONMENT REPORT <br /> Use to report plugging and sealing of permitted waits.monilonng end other toles. 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 Penult Number of the well being plugged 240328 or <br /> MH File Number MH- Hole ID*Name MMWA ; 2014 a <br /> I IndiMuaUComganv responsible for Ougging and sealing the welt 1 <br /> Name(s) Transit Mix of Pueblo <br /> Mailing Address 444 E Costills St. <br /> City,St.,Zip Colorado Springs.CO 80903 <br /> Phone(area code&no.) 719.476-0700 Email: <br /> Wep(Hob)Owner -- <br /> ` NAMES) Transit Mix of Pueblo Phone(include area code) 719475-0700 <br /> Mailing Address,City.St,Zip 444 E Costills St.Colorado Springs CO 80903 <br /> ACTUAL WELL LOCATION: County Pueblo <br /> Property Address,City,St Zip <br /> NVV tt4 of the�jQ(1/4,Sec. 34 ,Twp. 20 n N,or S..Range 84 ® E.or ® W., 6 P.M. <br /> t3istarwe from Section Lines 2481 Ft.from r N or 19 S., 172 Ft.from OE.or M W.Una. <br /> Subdivision Name Lot .Block ,Fiting/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 rl; Units must be meters;Datum must be NAD83,Unit must beset to fuse north. <br /> Easibng Northing --- -- _- — <br /> I(we)report the existing well(hole)was plugged and sealed on the daft of for the following reason(s): ; <br /> ❑The well was plugged and sealed as required under Well Permit Number <br /> ❑The weft was not in use and was plugged and sealed. <br /> Other(please explain) The well was located within a mining area that has been mired 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 /> intervals of casing reirovedlrlpped 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. 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 Date(mmlddlyyyyy) <br /> `'l�Gr>k klwve <br /> V <br /> - - - -- . A SQ1eS1 , di%;n <br /> It is the responsibility of the well owner to have the welVhole 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:hlhumphries2@comeast.net <br />