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Y ~ <br />STATE OF COLORADO <br />OFFICE OF THE STATE ENGiNE~R <br />eta Cxrtertniel etac., tsta St+ennert Se.. D.rnrer, eewrwo t~ <br />~T measet <br />E OR PRINT IN BLACK INK <br />WELL ABAND~IVMENT REPORT"~ <br />ABANDQNm WELL' NUM6ER -F REGISTEAE7 ~.~-9-7f- ~frD~ <br />NAME(S) gIARK (ERR <br />Mailing Address 490/ S. [Nr.uat>,4Mr~E <br />C1y, St. Z:p G. ~6,a, ~ c~. ~of~o <br />Phone (303 1 795- St3o <br />2~ ACTUAL WE'! LOCATION: COUNTY LA~s , <br />PROPERTI' AOORE55 3 /1(r~6S ERSr or <br />(Atldnre) <br />ia,DA~ <br />For Olriee Uw ony <br />AOO <br />~yGd~YZ~-~E Qma~ <br />S E t/a N ~ I/a, Sea ~~ Twp. 3 3 ~ N. m 5., Aange ~ 3 ^ E ~ W. ~ P.M. <br />Dlsranees Iron Seclon L[nes r 7 ~ FC hcm ~ N. ~ S. Une, ~ (~'3o FL from 0 E ar ~ W. Line. <br />(C:ry) (SLCej (~+l <br />I (we), report the an existing well was plugged and abandoned for the following. mason(s): <br />The welt was plugged and abandoned as required under the condlUons of <br />approval of Well Pertrtit No. <br />® The well was'not Irt use and was abandoned. <br />Cther (please explain) <br />a.l The well was plugged and abandoned ac~rding to the Water Weil Construction <br />and Pump Irtstallatlart Rules art NA' 195~.~. <br />5. The well was plugged with the following matertats placed at the indlcaed Irnervals: <br />AMCUNT AND 7YPE OF MATERIAL ME;'i-IOD OF PLAC'c?v1ENT INTcnVAL <br />jy c.f ~'~.~c.~.T SA,vil , ware ~.~ S~ 1~3eti_ tram_~fee! to a °O feet <br />from feet to feet . <br />tram feet to fee*. <br />from feet to feet <br />1!4'x;=VhLS CF ~15R:G R~CVp.¢tIP?~ IN F'~ from feet to fe <br />from feet to feet <br />6. I (we) have read the statements made herein and know the cements thereof, and that they are we to rtry (cur) <br />knowledge. (Pursuarn to Sec;ioh 2a-~-t 0a (13)(a) C.R.S„ the making of false statements herein consttttttes perjur <br />fn the second degree and is punishable as a doss 1 misdemeanor,) <br />Name/7'rUe (Please type or prim) Signature ~G~f" ~ i Date <br />-INFCRMAT70N- It is the responsibility of the well owner to have the well properly plugged and abandcned. <br />The well constrvrion eamtaetor Is responsible far nattfying the well owner of the plugging and abandonment reauiremai <br />This tortrt may tre reproduced by photocopy or ward proeessfrtg means <br />