HYDRO22148

• Permit No: M1980244
• IBM Index Class Name: Hydrology
• Doc Date: 4/6/2001
• Doc Name: WELL ABANDONMENT REPORT
• Media Type: D
• Archive: No

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Form STATE OF COLORADO 999
For OfSce Use Only
No. OFFICE OF THE STATE ENGINEER
GWS-09 g21 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
06/00 [phone] Fax [phone]
WELL ABANDONMENT REPORT
Type or Drint in black ink.
Well Permit Number of the well being plugged IG M W - I
IndividuallComoanv responsible for plugging and sealing the well:
NAME(S) C~CCC.~~~~ L~d Gc~~. n~~p,
Mailing Address P ~ O. ~YJX ~`~ I
City, SL Zip ~ ~ c~or ~ 8086 ~
Phone (719 ) X89 - 't0 ~l
ACTUAL WELL LOCATION: County Te.1~ ___
Property Address __ ~.
__
(Address) (City) (State) (Zip) ,
_1!4 of the Nt 1/4, Sec. ~, Twp. ys ^ N. or ~ S., Range 6q ^ E. or©W., ~P.M.
f
i
Li
F
^
^
^
^
rom Sect
on
nes
l. From
Distance
E. or
N. or
S., Ft. From
W. Line.
Subdivision Name _ Lot ,Block , Filing/Unit __
I (we) report that an existing well was plugged and sealed for the following reason(s):
l
^ Th
ll
l
d
d
d
i
m
an
e we
was p
ugge
sea
e
as requ
red under Well Per
it Number ____
ll
i
l
® Th
d
d
l
was not
n use an
was p
e we
ugge
and sea
ed.
h
l
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i
^
n) _
er (p
ease exp
a
Ot

The date the well was plugged according to the Water Well Construction Rules was (2 - Ifo - 00
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type of Material Method of Placement Interval
.BOO 16s_ 3~a ~ ben~on.~a chrp~ BekFe~, un from ~(Z feet to _y 5 feet
AyA reed dur,w.a, Pbccm.,.+
loo 16s - ~crn~,.t Lieke~. ' up from _~_ feet to O feet
from feet to feet
from feet to feet
Intervals of casing removed/ripped in feet from feet to feet
I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
Please print the Signer's Name & Title Signau
r
e(
s) Date
Scram, fl , Z.e is l ~ ~
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~(~/Ll ~ (~.~G~, -

_1`1a~ncxcatr ~r.v, A Ynsu~rc
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It is the responsibility of the well owner to have the well properly plugged and sealed. The Well Construction Contractor is
responsible for notifying the owner of this requirement.