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FORM STATE OF COLORADO For Ottiee Uaa only <br />No' OFFICE OF THE STATE ENGINEER <br />G W S-9 <br />12l95 <br />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 />(ro Report Pluppinp and Saalinp Wellel 471 84F Sw'1 <br />PERMIT NUMBER OF PLUGGED WELL <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 1 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas <br /> PROPERTY ADDRESS 14300 Highway 12 wactnn, r•n atngt <br /> Ulddresl (City) _ "(Stara) ~~ '. (2tp) <br /> SW 1/4 NE 1/4, Sec. 23 Twp. 33 ^N. OS., Range 68 ^E; ®yy,1.~ 6th p,M, <br /> Distances from Section Lines 2325 Ft. from ^x N. ^S. Line,2200 Ft. from^x E. or^W. Line <br />3. I (we), report that an existing well was plugged and sealed for the following reasdri(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 WeII Construction <br /> Rules on June 16 1 g 99 , <br />5. The well was plugged with the following materials Qlaced at the indicated intervals: <br /> AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL <br /> Clean Sand ~ from 23 feet to B ~ feet <br /> Bentonite - from 8 .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 /> Casing could not be removed <br />from feet to feet <br />6. I (wel have read the statements made herein and know the contents thereof, and that they aro true to my (our) <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) Sig ture Date <br />~ <br />w <br />!C ` <br />~ ~ Z5~S5 <br />~ <br />e~ <br />~ <br />i <br />I . <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 />