HYDRO22148

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

Form STATE OF COLORADO For Office 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 print in black ink.
Well Permit Number of the well being plugged WPM ~ ~-S
Individual/Cgmpanv responsible for plugging and sealing the well: ,
NAME(S) ~r;o~D~e. Creek ~' ~Tc~-.or ~o)c~ h1~n;r,a Go.
Mailing Address P ~ D , g oX / 9 /
CO SO S/o O
City, St. Zip V ~ C~.or
i
Phone (719) 6 89 - ~~ S~/
ACTUAL WELL LOCATION: County _ T~1I e.r
Property Address

(Address)
(City) __
(State) (Zip)
I I
\1 tJ114 of the Swt /4, Sec. ~, Twp. /~S J N. or®S., Range 69 ^ E. or ®W., ~ P.M.
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Li
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ance
rom
ec
on
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rom
s
N. or
S., Ft. From E. or
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
d
d
l
d
i
e we
was p
ugge
an
sea
e
as requ
red under Well Permit Number _
The well was not in use and was plugged and sealed.
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i
^ O
er (p
ease exp
n) _
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a

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:
Amou
n
t
and Type of Material Method of Placement Interval
'
1
_
_~QtZf~ - 3/eon ~r~~en,~e cti~ps hyd~l' from~(o feetto_~feet
dw...c~ ~Ir+ca,.
~
00I l~ew..~yi' 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 8 Title Sign refs) Date
_~ot~ R. I~.,a,b
_J`~o.r~~
E,.,,. A~ra~rs ~ 6 D
t
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 oT this requirement.