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09/2016
<br />INSTRUCTIONS FOR WELL ABANDONMENT REPORT
<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 />___________________________________________ ______________________________ from _______ feet to _________ feet
<br />___________________________________________ ______________________________ from _______ feet to _________ feet
<br />___________________________________________ ______________________________ from _______ feet to _________ feet
<br />Intervals of casing removed/ripped in feet from _______ feet to _________ feet
<br />I (we) report the existing 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 /> The well was not in use and was plugged and sealed.
<br /> Other (please explain) _______________________________________________________________________________________
<br /> __________________________________________________________________________________________________________
<br />ACTUAL WELL LOCATION: County __________________________
<br />Property Address, City, St, Zip_____________________________________________________________________________________
<br />_____1/4 of the____ 1/4, Sec. ____, Twp. ______ N. or S., Range ______ E. or W., ____ P.M.
<br />Distance from Section Lines ________ Ft. From N. or S., _________ Ft. From E. or 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 or zone 13 ; Units must be meters; Datum must be NAD83; Unit must be set to true north.
<br />Easting _____________________ Northing ________________________
<br />Well (Hole) Owner:
<br />NAME(S) _________________________________________________________ Phone ( ) _____________________________
<br />Mailing Address, City, St., Zip ______________________________________________________________________________________
<br />Form No
<br />GWS-09
<br />03/2017
<br />2.Individual/Company responsible for plugging and sealing the well:
<br />Name(s) ___________________________________ License # ________________
<br />Mailing Address __________________________________________________________
<br />City, St., Zip ____________________________________________________________
<br />Phone ( ) ________________ Email ____________________________________
<br />WELL ABANDONMENT REPORT
<br />Use to report plugging and sealing of permitted wells, monitoring and other holes. Type
<br />or print in black or blue ink. Instructions and plugging standards are on reverse side
<br />form.
<br />4. Well Location Address: __________________________________________________________________________________
<br />5.GPS Well Location: County __________________________
<br />UTM Zone 12 or Zone 13 Easting _____________________ Northing ________________________
<br />6. Legal Location: ___1/4 of the ___ 1/4, Sec ____, Twp _____ N or S , Range _____ E or W , ____ P.M.
<br />Distance from Section Lines ________ Ft. From N or S , _________ Ft. From E or W Line.
<br />Subdivision Name ___________________________________ Lot ________, Block ______, Filing/Unit _______
<br />
<br />11.Signature(s)
<br />____________________________________
<br />____________________________________
<br />Date
<br />____________________
<br />____________________
<br />Please Print the Name, Title, & License No.
<br />________________________________________
<br />________________________________________
<br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor is
<br />responsible for notifying the owner of this requirement in writing.
<br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
<br />1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581
<br />dwr.colorado.gov and dwrpermitsonline@state.co.us
<br />For Office Use Only
<br />1.Well Permit Number of plugged well __________ or MH File Number MH- ____________
<br />Owners Well Designation- ___BBBBBBBBBBBBB _________Receipt Number: _____________
<br />9.Intervals of Casing Removed/Ripped:
<br />from ________ feet to _________ feet, from ________ feet to _________ feet, from ________ feet to _________ feet,
<br />from ________ feet to _________ feet, from ________ feet to _________ feet, from ________ feet to _________ feet,
<br />10.Amount and Type of Material Method of Placement Interval
<br />____________________________________ _________________________ from _________ feet to _________ feet
<br />____________________________________ _________________________ from _________ feet to _________ feet
<br />____________________________________ _________________________ from _________ feet to _________ feet
<br />____________________________________ _________________________ from _________ feet to _________ feet
<br />I have read the statements made herein and know the contents thereof, and they are true to my knowledge. This document is si gned (or name entered
<br />if filing online) and certified in accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402 2. The filing of a document that contains
<br />false statements is a violation of section 37 91 108(1)(e), C.R.S., and is punishable by fines up to $1,000 and/or revocation of the contracting license. If
<br />filing online the State Engineer considers the entry of the licensed contractor’s name to be in compliance with Rule 17.4.
<br />7. I/we report the existing well/hole was plugged and sealed on ____________________ (date) for the following reason(s):
<br /> 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 /> Other (please explain) __________________________________________________________________________________
<br />8. Aquifer Type: Type I (One Confining Layer) Type I (Multiple Confining Layer) Laramie-Fox Hills
<br /> (check one) Type II (Not Overlain by Type III) Type II (Overlain by Type III Type III (alluvial)
<br />3.Well (Hole) Owner: Name(s): ___________________________________________________________________
<br />Phone: ( ) _______________________ Email: __________________________________________________________
<br />Mailing Address, City, St., Zip: ______________________________________________________________________________
<br />60095-MH
<br />POC-7
<br />Cascade Drilling 1566
<br />1380 South Cherokee Street
<br />Denver, CO 80233
<br />303 423-2547
<br />Colowyo Coal Company L.P.
<br />970 824-1200 ttennyson@tristategt.org
<br />5731 State Highway 13 Meeker, CO 81641
<br />5731 State Highway 13 Meeker, CO 81641
<br />Moffat
<br />n 264964.0 4469888.7
<br />NW NW 31 4 n 92 n 6
<br />03/29/2021
<br />4 60095-MH
<br />n
<br />0 5
<br />1.09 cubic feet clean sand Poured 5 32
<br />0.17 cubic feet bentonite Poured 0 5
<br />Mike Martin Mike Martin, SR Operations Manager, #1566 03/30/2021
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