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FORM STATE OF COLORADO For offiee Use only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-9 <br />12/95 818 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 <br /> 303 888-3581 ' <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />(io Report Plugging end Sealing Wells) <br />PERMIT NUMBER OF PLUGGED WELL 22416 Mb•l , <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> <br /> NAME(S) Grevstone Consultants <br /> Mailing Address 5231 South Quebec <br /> City, St. Zip Greenwood Village. O 80111 <br /> Phone (303 ) 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas <br /> PROPERTY ADDRESS _ 14300 Highway 12 WPCf•nnr r•~ Rt not <br /> (Address) ICityl - (Slits) Qip) <br /> SW 1/4 NE 1/4,Sec. 23 Twp. 33 ^N. ©S.,Range68 ^E, ®yy, .6th p,N], <br /> Distances from Section Lines 2375 Ft. from ©N. ^ S. Line, 2100 Ft. from x^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 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 /> Clean Sand from 13 feet to ~ 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 IN FEET from feet to feet <br /> Casing could not be removed <br />from feet to feet <br />6. I Iwe) have read the statements made herein and know the contents thereof, and that they aro true to my lour) <br />knowledge. [Pursuant to Section 24-4-104 (1311a- 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 />rc ~ IJ G.Qolb ~J 6~~ /S <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 word processing means. <br />