Laserfiche WebLink
FORM STATE OF COLORADO For Offiee Usa only <br />No. OFFICE OF THE STATE ENGINEER <br /> <br />GWS-9 <br />12/95 <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 />(To Report Pluppinp and Seelinp Wallal <br />su-3 <br />PERMIT NUMBER OF PLUGGED WELL 4Zt84F <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) Grevstone Consultants <br /> Mailing Address 5231 South Quebec <br /> City, St. Zip Greenwood Villaoe. CO 80111 <br /> Phone (303 ) 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas <br /> PROPERTY ADDRESS 14300 Highway 12 wPS}nnr rn Rtngt <br /> (Address) - (City) - (Starts) (Lpl <br /> SW 1/4 NE 1/4, Sec. 23 Twp. 33 ^N. OS., Range 68 QE, ®yy, 6th p,M, <br /> Distances from Section Lines 2375 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 grid sealed for the following reasori(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 , 1y 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 23feet to 8 feet <br /> Bentonite - - from e ~ 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 from feet to feet <br />6. I Iwe) have read the statements made herein and know the contents thereof, and that they are true m my lour) <br />knowledge. [Pursuant to Section 24-4-104 (131(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 />/V rc% <br />/6 <br />E ~ ~~Zr~~ (o/.t5 /s <br />S ~~1 <br />zcl~ ~f <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 />