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FORM STATE OF COLORADO For Office Use only <br />No. OFFICE OF THE STATE ENGINEER <br /> <br />GWS-9 <br />12/95 <br />g18 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 _ <br /> 303 888-3581 - <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />fro Report Pluppinp and Saalinp Walla) 4 71 84F S W <br />PERMIT NUMBER OF PLUGGED WELL <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> i <br />NAME(S) Grevstone Consultants ;d. <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 41PCrnr, r en R1 n91 <br /> (Addreee) ICityl .- (State) ~ 4 ItiPl <br /> SW 1/4 NE 1/4, Sec. 23 Twp. 33 ^N. ~S., Range 68 ^E, ®V11, 6th p,M, <br /> Distances from Section Lines 2475 Ft. from ^x N. ^ S. Line, 2200 Ft. from ©E. or^ W. Line ~ <br />3. 1 (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 lg 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 /> Sentonite - 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 <br />from feet to feet <br />6. I Iwel have read the statements made herein and know the contents thereof, and that they are true to'ery (our) <br />knowledge. (Pursuant to Section 24-4-104 (1311a1 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) Sign ture Date <br />/G <br />K ~/.i s/s 5 <br />l <br />5 r <br />oo%~~ ,~ <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 />