Laserfiche WebLink
FORM <br />r1o STATE OF COLORADO For OHiee Use only <br />. 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 />(To Report Pluppinp and Saelinp Wallal <br />22416 M~-4 <br />~i <br />PERMIT NUMBER OF PLUGGED WELL <br />1. INDIVIDUALlCOMPANY RESPONSIBLE FOR PLUGGING <br /> <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 14300 Highway 12 waatnn~ r•n R1n91 <br /> (Addreaa) ~ ICityl - - IStaal :.. Qlpl <br /> ®yy, 6th p,M, <br />SW 1/4 NE 1/4, Sec. 23 Twp. 33 ^N. ~S., Range 68 ^E, <br /> ~~xx- <br />Distances from Section Lines 2550 Ft. from ®N. ^ S. LIne50 Ft. from L_l E. or ^ W. Line <br /> -~ <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 16 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 1 6 feet to 8 feet <br /> Bentonite - - from a feet to 0 'r 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 (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 />NamelTitle (Please type or print) Signature Date <br /> 6/-~S/ <br />rc eo ~, <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 />