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DocuSign Envelope ID:3950C452-4A36-4859-BBA9-43B2A119378F <br /> Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER I For Office Use Only <br /> GWS-09 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> 03/2017 dwr.colorado.ci and dwrgermitsonline®state.co.us <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 /> 1. Well Permit Number of plugged well 302717 or MH File Number MH- <br /> Owners Well Designation- MW-BF-66 Receipt Number: 3675985H <br /> 2. Individual/Company responsible for plugging and sealing the well: <br /> Name(s) Cascade Remediation Services _ License# 1566 <br /> Mailing Address 1380 S Cherokee Street <br /> City, St., Zip Denver, CO 80223 <br /> Phone ( 303 ) 423-2547 Email mmartinCcascade-env.com <br /> 3. Well (Hole) Owner: Name(s)• Elk Ridge Mining and Reclamation, LLC - New Horizon Mine <br /> Phone: ( 303 ) 452-6111 Email: chris.gilbreath@tristategt.org <br /> Mailing Address, City, St., Zip: P.O. Box 33695, Denver, CO 80233-0695 <br /> 4. Well Location Address: <br /> 5. GPS Well Location: County Montrose <br /> UTM 0 Zone 12 or Zone 13 Easting 712081.0 Northing 4239111.0 <br /> 6. Legal Location: NW.1/4 of the NW 1/4, Sec 6 , Twp 47 0 N or S❑, Range.. 1.6 ._ ❑E or W Q NM_ P.M. <br /> Distance from Section Lines 440 Ft. From :L N or S i'I -.. -40-_— Ft. From IES E or W�...L Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. Uwe report the existing well/hole was plugged and sealed on 11/14/2023 (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) Well no longer needed <br /> 8. Aquifer Type: p Type I (One Confining Layer) p Type I (Multiple Confining Layer) E3 Laramie-Fox Hills <br /> (check one) © Type II (Not Overlain by Type III) ©Type II (Overlain by Type III E3 Type III (alluvial) <br /> 9. Intervals of Casing Removed/Ripped: <br /> from 0 feet to 5 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 /> Clean Sand Tremied from 79 feet to 109.2 feet <br /> Bentonite Chips - Hydrated Tremied from 5 feet to 79 feet <br /> Native Soil Gravity from 0 feet to 5 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 signed (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 1080)(e), C.R.S., and is punishable by fines up to$1,000 and/or revocation of the contracting license. !f <br /> fHim nnlinP the Stator FnainPar ronvulP ntry of the lirPncwi rnntrartnr'c name to hp in rmmniianrP with R1110 17 4 <br /> 11. Signature(s) Please Print the Name, Title, 8: License No. Date <br /> MCk&MCt*- yv Mike Martin, Project Manager, 1566 11/21/2023 <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 />