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FORM STATE OF COLORADO For Otfiee Uee only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-9 <br />12/95 818 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 III IIIIIIIIIIIII III <br /> 303 888- 58 <br />TYPE OR PRINT IN BLACK INK ~-999 -_~ <br />WELL ABANDONMENT REPORT <br />Ro Report Pluppinp end Seelinp Wslls) <br />2241 6 <br />PERMIT NUMBER OF PLUGGED WELL M~'~ <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) Grevstone Consultants <br /> Mailing Address 5231 South Quebec <br /> City, St. Zip Greenwood Villages CO 80111 <br /> Phone (303 ) 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas - <br /> PROPERTY ADDRESS 14300 Highway 12 taPC}nn~ cn'R1ogt~ <br /> (Address) (City) _~ ~ ,(Stela) ', '(Zipl <br /> SW_1/4 NE 1/4,Sec. 23 Twp. 33 ^N. ,x^S.,Range68 ^E,-®yy, 6th p,M, <br /> Dis ancesfrom Section Lines 2300 Ft. from©N. ^S. Line, 800 Ft. from^E. or~ W. Line <br />3. I (we), report that an existing well was plugged and sealed for the follow'ing'naason(s): ' <br /> _ :~ ~: :; <br />^ The well was plugged and sealed as required under the conditions of ~ , <br /> approval of Well Permit No. <br /> ® The well was not in use and was plugged and sealed. <br /> ^ Other (please explain) <br /> <br />4. The well was plugged and sealed according to the Water Well Construction <br /> Rules an June 16 1 g 99 <br />5. The well was plugged with the following materials placed at the indicated intervals: <br /> AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL <br /> C.Lean Sand from ~ feet to 14 feet <br /> Bentonite - from 7 feet to 0 . -feet <br /> from feet to ~ - =feet <br /> from feet to feet <br /> INTERVALS OF CASING REMOVED/RIPPED fN FEET from feet to feet <br /> Casing could not be removed from feet to feet <br />6. I Iwe) have read the statements made herein and know the contents thereof, and that they are true to my (our) <br />knowledge. [Pursuant to Section 24-4-104 11311a) C.R.S., the making of false statements herein constitutes perju <br />in the second de ree and is unishable as a class 1 misdemeanor.) <br />Nameffitle (Please type or print) S <br />e Date <br /> <br />~~ <br />G ~1 <br />~ /~~~ <br />/ <br />"' <br />~ <br />~~~'L~ <br />~ <br />~/ /s <br />s <br />r <br />,~ l f i <br />H <br />r~ <br />--INFORMATION-- It is the responsibility of the well o~,ner to have the well properly plugged and sealed. The Well <br />Construction Contractor is responsible for notifying the well owner of the plugging and sealing requirement. <br />This farm may be reproduced by photocopy or word processing means. <br />