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RPM,Inc. <br /> form No. STATE OF COLORADO,OFFICE OF THE STATE ENGINEER For Oflim Use Only <br /> CIWS-09 821 Centennial Bldg.,1313 Sherman St.,Denver,CO 80203 <br /> 4ROI2 (303)866-3581 Fax(303)866-3689 dwrvermitson(ingQstate.co us <br /> WELL ABANDONMENT REPORT p r_ t—;;;!— <br /> Use to report plugging and seshng of permitted wells,monitoring and other holes. This form can be ' - <br /> computer generated,typed or printed in blade or due ink Instructions and plugging standards are on <br /> reverse side of loan. <br /> -. ---- - - -- --- — --- �'IL I i 2014 <br /> Well Permit Number of the well being plugged 281529 or <br /> MH File Number MH- Hole ID ttt/Name MW-199 "S <br /> IndividuaUCompanv responsible for plugging and sealing the well: <br /> Name(s) Transit Mix of Pueblo ' <br /> Mailing Address 444 E Costille St- <br /> City.St,Zip Colorado Springs,CO 80903 <br /> Phone(area code A no.)719.475-0700 Email <br /> Weil(Hob)Owner. <br /> NAMES) Mark Klune Phone(include area code) 719-561-8350 <br /> i <br /> Mailing Address,City,St.,Zip PO Box 857 Pueblo CO 81002 <br /> ACTUAL WELL LOCATION: County Puebb <br /> Property Address,City,St,Zip <br /> JA_1/4 of theJeM 1/4,Sec- 34 ,Twp. 20 f-i N.or IKI S.,Range 64 0 E.or O W. 6 P.M. <br /> Distance from Section Lines 108 Ft from rl N.or 99 S., 1212 Ft from ❑E or M 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 fo lows. <br /> Format must be UTM, zone 12 77 or zone 13 ITI; Units must be meters,Datum must be NAD83;Unit must be set to true north. <br /> Easting 539572 Northing 42346M <br /> j I(we)report the exisbng well(hole)was plugged and sealed on the date of for the following reason(s) <br /> i <br /> f 0 The well was plugged and sealed as required under Well Permit Number <br /> The well was not in use and was plugged and sealed. <br /> j Other(please exptain) 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 /> Intervals of casing removeWripped in feet from feet to feet <br /> Report mlit:I be sand or name entered by person who perlom►ed the weft plugging work or by"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 8 tube Date(mm/dd/yyyyy) <br /> i1 / jQrk l� lvNda <br /> Scr�kxo/ Ad m;n Or7-t _.Ao l Ai <br /> It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Constvchon Contractor <br /> is responsible for notifying the owner of thus requirement. <br /> RPM,Inc.,25049 E.Alder Dr.,Aurora,CO 80016 Phone:(303)854-7499 Email:h1humphries2@comcast.net <br />