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FORM STATE OF COLORADO For ONice Uae only <br />No. OFFICE OF THE STATE ENGINEER <br /> <br />GWS-9 <br />12/95 <br />e18 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 _ <br /> 303 888-3591 <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT : , . <br />(To Report Pluppinp and Seelinp Wellal <br />. 2241 6 -1W-3 <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 ) 850-0930 <br />2. ACTUAL WELL LOCATION: COUNTY Las Animas <br /> PROPERTY ADDRESS 19300 Highway 12 Waaf•nn <br />(`O at not <br /> ~ <br />IAddren) fcity) _ fStrte) ~ Qip) <br /> SW 1 /4 NE 1 /4, Seo. 23 Twp. 33 ^ N. L'kJ S., Range 68 ~ • • ^ E,~ ®V1I, .6th p,N]. <br /> Distances from Section Lines 2450 Ft. from ~N. ^S. Line, 2300 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 />. <br /> ^ The well was plugged and sealed as required under the conditions of <br />- <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 /> Rutes on June 16 19 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 ~ feet to 13 feet <br /> Bentonite - - from ~ 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 zemoved <br />from feet to feet <br />6. I (we) have read the statements made herein and know the contents thereof, and that they are true to my lour) <br />knowledge. [Pursuant to Section 24-4-104 113)la) 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 />NamelTitle (Please type or print) Sig ature Date <br />i~ 5 G,r /Gca/o , ~ 6/~5/ <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 />