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FORM STATE OF COLORADO For Ofiiee Use only <br />No. OFFICE OF THE STATE ENGINEER <br /> <br />GWS-9 <br />12/95 <br />g18 Centennial Bldp., 1313 Shsrrnen St., Denver, Colorado 80203 _ <br /> 303 888-3591 <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />ITo Report Pluppinp and Sedinp Walla) <br />PERMIT NUMBER OF PLUGGED WELL 22416 Mw-7. , <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) Grevstone Consultants <br /> Mailing Address 5231 South Quebec <br /> City, St. Zip Greenwood Village. CO 80111 <br /> Phone (303 ) 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas <br /> PROPERTY ADDRESS 14300 Highway 12 wPgt„n, rr Rlnal - <br /> IAddreee) (City) _ .. (Starts) .,..QIP) <br />~ <br /> 6th p,M, <br />SW 1/4 NE 1/4,Sec. 23 Twp. 33 ^N.OS.,Range68 ^E,1®yy,• <br /> Distances from Section Lines 2200 Ft. from ON. 21 00 ^x E. or^ W. Line <br />^ S. Line, Ft. from <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 ~ ° ~ , 19 - <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 Well covered and lost from feet to ' N' "feet <br /> Bentonite - - from feet to feet <br /> from feet to feet <br /> from feet to feet <br /> INTERVALS OF CASING REMOVED/RIPPED IN FEET from feet to feet <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 conathutes 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 />K ~~z5/S <br />)c <br />9 eo o rf <br />--INFORMATION-- It is the responsibility of the well owner to have the well properly plu99ed 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 />