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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Forrn STATE OF COLORADO For Office Use Onty
No. OFFICE OF THE STATE ENGINEER
GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
06/00 [phone] Fax [phone]
WELL ABANDONMENT REPORT
Tvpe or print in black ink.
Well Permit Number of the well being plugged We M w- 7
IndividuallCompanv responsible for plugging and sealing [he well
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NAME(S) Cf : ~
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Phone ( 719) ~$9 _ S<D't'I
ACTUAL WELL LOCATION: County ZL~2,r
Property Address_
___
__
_
(Address) (City) (State) (Zip)
1/4 of the~(~11/4, Sec. 3) , Twp. ~_U N. or ®S., Range 69 ^ E. or ®W., ~ P.M.
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Subdivision Name _ Lot __, Block , Filing/Unit
I (we) report that an existing well was plugged and sealed for the following reason(s):
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The date the well was plugged according to the Water Well Construction Rules was
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type of Material Method of Placement Interval
llb 165 - Oury~rr~.~r•U,,••J~ Greif' _~3,~Vw.`- tip from ~_ feet to 5 feet
loa 16e - r ~e..~!- P,eHe.._- up from ~i 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 6 Title Sign re(s) Date
Sr..~i'~ A. ~~~5 ~ ~-, ' A
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KQr~aer Eno. A~o:.~S C~~"V

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 [his requirement.
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