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DocuSign Envelope ID:3950C452-4A36-4859-BBA9-43B2A119378F <br /> GWS-09 <br /> 09/2016 <br /> Instructions <br /> This report must be computer-generated online, typed or printed in BLACK OR BLUE INK and may be reproduced by <br /> photocopy or computer generation. Photocopy reproductions must retain margins and print quality. Attach additional <br /> sheets if more space is required. Each additional sheet must be identified at the top by the well owner's name, the <br /> permit number, form name/number and a sequential page number. Report depths in feet below ground surface. <br /> If filing online please see the FORM SUBMITTAL, PAYMENT OPTIONS, Et FEE SCHEDULE <br /> You may also save, print and email the completed form to: dwryermitsontine@state.co.us <br /> These reports must be completed and submitted to the Division of Water Resources, usually within 60 days of plugging <br /> and sealing the well/hole. <br /> Please refer to Form GWS-09A for the Standards for Plugging, Sealing, and Abandoning Wells and Boreholes <br /> Item Instructions: (numbers correspond with those on the front of this form) <br /> 1. Complete the well permit and receipt number for the abandoned well. <br /> 2. Complete the name and contact information for the person performing the abandonment work. <br /> 3. Complete the well owner name and contact information. <br /> 4. Complete the address where the abandoned well is located. <br /> 5. Provide the GPS location and County where the abandoned well is located. <br /> Colorado contains two (2) UTM zones. Zone 13 covers most of Colorado. The boundary between Zone 12 and Zone 13 <br /> is the 1081h Meridian (longitude). West of the 1081h Meridian is UTM Zone 12 and east of the 108th Meridian is UTM <br /> Zone 13. The 108th Meridian is approximately 57 miles east of the Colorado-Utah state line. On most GPS units, the <br /> UTM zone is given as part of the Easting measurement, e.g. 12T0123456. Check the appropriate box for the zone. <br /> 6. Complete the legal description location of the (abandoned) well. For wells located in subdivisions, the name, lot, <br /> block, and filing, must be provided. <br /> 7. Indicate the reason(s) for plugging and sealing the well/hole. <br /> 8. Indicate the aquifer in which the abandoned well was completed. <br /> 9. Indicate the intervals were casing was removed, perforated, or ripped. <br /> 10. Complete the amount, type, method of placement and interval placed of the sealing materials. <br /> 11. Complete the Name, Title, and License Number (if applicable) of the individual(s)who are responsible for the work <br /> performed. The report must be signed by the responsible party per Rule 17.4. If applicable, indicate if Professional <br /> Engineer or Professional Geologist in place of License Number. <br /> Rule 17.4 Certification - Work reports must be signed and certified as to accuracy and truthfulness of the <br /> information on the report by the well construction or pump installation contractors or authorized individuals <br /> responsible for the work performed by them or under their direction or supervision, or by the private driller or <br /> private pump installer if the work was performed by them. Such reports are deemed to be completed, signed and <br /> certified under oath. <br /> Submit completed report to: State of Colorado, Office of the State Engineer, 1313 Sherman St, Room 821, Denver, <br /> CO 80203. You may also save, print, scan and email the completed form to dwroermitsonline@Dstate.co.us <br />