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FORM STATE OF COLORADO For Oitiee Uas only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-9 <br />12/95 <br />818 Centennial Bldp., 1313 Sherman St., Dsnvar, Colorado 80203 <br /> 303 88a-35 1 <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />(To Report Pluppinp and Sadinp Wella) <br />PERMIT NUMBER OF PLUGGED WELL 2241 6 My-~ . <br />1 . INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) Grevstone Consultants <br /> Mailing Address 5231 South Quebec <br /> City, St. Zip Greenwood Villagg, CO 80111 <br /> Phone(303 ) 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas <br /> PROPERTY ADDRESS 14300 Highway 12 wpg}nr,- cn atngt <br /> (Addreaa) (City) T - (Stele) .. RIP) <br /> SW 1 /4 NE 1 /4, Sec. 23 Twp. 33 ^ N. O S., Range 68 ^ E, ®W, 6th p,M, <br /> Distances from Section Lines 2 3 ~ 5 Ft. from ~ N. ^ S. Line, 21 ~ 5 Ft. from ©E. or ^ W. Line <br />3. I (we), report that an existing well was plugged and sealed for the following reason(s): <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 on June 16 1g 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 /> Clean Sand ' from 1 3 feet t0 ~ feet <br /> Bentonite - from ~ feet to 0 feet <br /> from feet to feet <br /> from feet to feet <br /> INTERVALS OF CASING REMOVED/RIPPED IN FEET from feet to feet <br /> Casing could not be removed <br />from feet to feet <br />6. I (we) 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 (13-(a) 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 />Name(Title (Please type or print) Signature Date <br />Ge <br />l <br />~ 5 f i <br />N 6/a s~S 5 <br />o ~ <br />o <br />f <br />r <br />--INFORMATION-- It is the responsibility of the well owner 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 form may be reproduced by photocopy or ward processing means. <br />