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FORM STATE OF COLORADO For Dffiee Use only <br />nlo. <br />GWS-9 OFFICE OF THE STATE ENGINEER <br />- <br />12/95 819 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 <br /> 303 866-3581 <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />ITo Report Plugging end Sealing Wells) <br />Sw-S <br />PERMIT NUMBER OF PLUGGED WELL 47184F <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> <br /> NAME(S) Greystone 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 wacrnn <br />rn stoat <br /> ~ <br />(Addreasl (City) _ IStals) Rip) <br /> SW 1/4 NE 1/4, Sec. 23 Twp. 33 ^N. OS., Range 68 ^E, ®yl/, 6th p-M, <br /> Distances from Section Lines 2425 Ft. from ®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 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 1 6 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 23 feet to 8 feet <br /> Bentonite - - from 8 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 from feet to feet <br />6. I Iwe) have read the statements made herein and know the contents thereof, and that they are 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 />ame/Title (Please type or print) <br />N Signature Date <br />AA <br />// <br />/V(L < f (~evl~ ,J! /~ ~ ~7 <br />A ~ ~~5~95 <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 />