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FORM STATE OF COLORADO For Offiee Use only <br />No. OFFICE OF THE STATE ENGINEER <br /> <br />GWS-9 <br />12/95 <br />gt8 Centennial Bldp., 1313 Sherman St., Denver, Colorado 80203 _ <br /> 303 888-3581 ' <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />ITo Report Plupginp and Seelinp Wallsl <br />2241 6 Hv-S <br />PERMIT NUMBER OF PLUGGED WELL <br />1. INDIVIDUAL/COMPANY 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 taPat•r,nr rn Rt ngt <br /> Ulddrewl (City) _ (State) ~.IZlpl <br /> Sw 1/4 NE 1/4,Sec. 23 Twp. 33 ^N. OS.,Rarige68 ^E, ®yy, 6th p,M, <br /> Distances from Section Lines 2400 Ft. from ON. ^ S. Line,2225 Ft. from ©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 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 3 feet t0 ~ feet <br /> Bentonite - - from 7 -feet to 0 ~ =Meet <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 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 constittrtes perju <br />in the second de ree and is unishable as a class 1 misdemeanor.) <br />NamelTitle (Please type or print) Sip ature Date <br />I c f Geo/a if G/~ /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 />