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Form No.
<br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
<br />For Office Use Only
<br />GWS-09
<br />6/2006
<br />821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
<br />(303) 866-3581 Fax (303) 86&3589 W://www.water.sWe.co.us
<br />O C T 0 4 2007
<br />WATER RESOURCES
<br />WELL ABANDONMENT REPORT
<br />Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or
<br />STATO BNGIlyar"
<br />coLO.
<br />print in black or blue ink. instructions and plugging standards are on reverse side of form.
<br />Well Permit Number of the well being plugged 19 7 3-1 ITC— I or
<br />MH File Number MH- Hole ID #/Name
<br />Individual! om� n responsible forMlu in and -sealing the well:
<br />`+
<br />NAMES) W I IACO,onL>r I
<br />Mailing Address f 0 ey 1 ;2
<br />City, St.,cZip C-cc o-r � Cp Q e, , C,� 8 (� 3
<br />r
<br />Phone !�tZr d )
<br />Well (Hale) Owner: , p n
<br />®1(t�ow bow by n �'"► I i1�Q-1 5, �tlG �`?O)
<br />NAME(S) (
<br />Mailing Address, City, St., Zip _' 01nf-- 'Se � I CAD 5� 1'A -54- ,1Phone
<br />ACTUAL WELL LOCATION: County GL-Lyk-V1 i 5,5 ri
<br />Property Address, City, St, Zip
<br />5S 1l4 of the N W114, Sec. _�J,,,, Twp. 13 E] N.14 S., Range zS 9 E. orjl(j W., _(0 P.M.
<br />Distance from Section Lines W0 Ft. From W N. or [] S., 110 0 Ft. From ❑ E. oro W. Line.
<br />Subdivision Name Lot , Block , Filing/Und
<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 ❑ or zone 13 0 ; Units must be meters; Datum must be NAD83; Unit must beset to true north.
<br />Easdng Northing
<br />I (we) report the existing well (hole) was plugged and seated on the date of for the following reason(s):
<br />O The well was plugged and sealed as required under Well Permit Number
<br />I,at The well was not in use and was plugged and seated.
<br />b Other (please explain)
<br />The well was plugged with the fallowing materials placed at the indicated intervals:
<br />Amount and Type of Material Method of Placement Interval
<br />15,�5, Cal I M1,5 N Mf Ce fn e fit 51 fide D �-, p �EMeM,f- from o' -1 a. Q'
<br />feet to feet
<br />�' " IP0
<br />l IJ0. ` (f MC� +t)-T �10.�wrr.51/t�Q.4er from feet to feet
<br />nn ,
<br />Li 0. S 1 n etnW ifat from © feet to -mil' feet
<br />Intervals of casing removed/ripped in feet M5 per,, ,��,, -+,A from 6 80 ' feet to `T d'ZO' feet
<br />Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. I
<br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
<br />Signature(s)
<br />Please print the Signer's Name & Title
<br />Date
<br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor
<br />is responsible for notifying the owner of this requirement.
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