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Form No STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br /> GWS-09 1313 Sherman St., Room 818, Denver, CO 80203 303.866.3581 <br /> dwr.colorado.go\ and .vrpermitsonlinev)state.co.0<, <br /> 02/2024 <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 26211-F or MN File Number MH- <br /> Owners Well Designation- BH836-11 Receipt Number: 9063186 <br /> 2. Individual/Company responsible for plugging and sealing the well: <br /> Name(s) QUALITY WELL & PUMP License# 1461 <br /> Mailing Address P.O. BOX 577 <br /> City, St., Zip GREELEY, CO 80632 <br /> Phone ( 970 ) 353-3118 Email kristie@qualitywellandpump.com <br /> 3. Well (Hole) Owner: Name(s): ROCKY MOUNTAIN ENERGY/POWERTECH <br /> Phone: ( 605 ) 517-0251 Email: leakin®encoreuranium.com <br /> Mailing Address, City, St., Zip: PO BOX 173779, DENVER, CO 80217 <br /> 4. Well Location Address: CR 23 Ft CR 94, PIERCE, CO 80650 <br /> 5. GPS Well Location: County WELD <br /> UTM 0Zone 12 or 0Zone 13 Easting 512690.0 Northing 4502041.0 <br /> 6. Legal Location: SE 1/4 of the SE 1/4, Sec 11 , Twp 8 Q N or S❑, Range 67 0 E or W D , 6TH P.M. <br /> Distance from Section Lines 90 Ft. From © N or S Q , 87 Ft. From Q E or W Q Line. <br /> Subdivision Name Lot , Block , Filing/Unit <br /> 7. I/we report the existing well/hole was plugged and sealed on 04/05/2024 (date) for the following reason(s): <br /> The well was plugged and seated as required under Well Permit Number <br /> ✓ The well was not in use and was plugged and sealed. D This is the abandonment of a dry hole, <br /> Other(please explain) not the permitted well <br /> 8. Aquifer Type: ❑ Type I (One Confining Layer) ❑Type I (Multiple Confining Layer) 9 Laramie-Fox Hills <br /> (check one) 0 Type II (Not Overlain by Type III) 0 Type II (Overlain by Type III 0 Type III (alluvial) <br /> 9. Intervals of Casing Removed/Ripped: <br /> from +2 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 /> 2CUBIC FT NATIVE SOILS SHOVELED from 0 feet to 5 feet <br /> 2 CU. FT PORTLAND TYPE I/II CEMENT POURED from 5 feet to 12 feet <br /> 20 BAGS 3/8" BENTONITE CHIPS POURED from 12 feet to 71 feet <br /> 23 CU. FT 6/9 SILICA SAND POURED from 71 feet to 154 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 if <br /> 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 false <br /> 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 filing <br /> online the State Engineer consi'• the entry of the licensed contractor's name to be in compliance with Rule 17.4. <br /> 11. Signature(s) Please Print the Name, Title, Et License No. Date <br /> 0,hyiware.1( ane,5 Li i 15 lao <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 /> i <br />