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. ;\ <br />5 <br />Form STATE OF COLORADO For Office Use Only <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-09 g21 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />06/00 (303) 866-3581 Fax (303) 866-3589 <br />WELL ABANDONMENT REPORT <br />Type or print in black ink. ~ V fWtnl - 13A <br />Well Permit Number of the well being plugged____________. <br />Individual/Company responsible for plug ing and sealing the well: <br />NAME(S) --e C ~ U CZcld~ ~ (troy- ~~ ------ <br />0 <br />Mailing Address __~D ~01< ~~'1( <br />City, SL ZiP __~t(~~! NCO _~U S(o U <br />Phone (3rg) _c~l3q- aq~? ___ <br />ACTUAL WELL LOCATION: County _~ ~Iol ______________ <br />Property Address_a?55 S}~(c I-~rch~~(gZ_________Utc~nr__ _______C_U ~08~U <br />(Addres) (City) (State) (Zip) <br />_~ f _114 of [hel/ W1/4, Sec. t] , Twp. __LS __U N. or ®S., Range __( ~ ^ E. or ©W., `~ P. M. <br />Di <br />f <br />S <br />i <br />Li <br />F <br />F <br />^ <br />^ <br />^ <br />^ <br />stance <br />rom <br />ect <br />on <br />nes ________ <br />t. <br />rom <br />N. or <br />S., ______ Ft. From <br />E. or <br />W. Line. <br />Subdivision Name Lol ________, Block ______, Filing/Unit ____ <br />I (we) report [hat an existing well was plugged and sealed for the following reason(s): <br />Th <br />l <br />l <br />l <br />i <br />ll P <br />N <br />e we <br />l was p <br />ugged and sea <br />ed as requ <br />red under We <br />umber _ <br />ermit <br />t i <br />^ Th <br />ll <br />l <br />d <br />d <br />l <br />d <br />was no <br />e we <br />n use and was p <br />ugge <br />an <br />sea <br />e <br />. <br />^X Other (please explain) __ wcll _r\of~roperl~_Co~nsi_._rACf~_________________- <br />The date the well was plugged according to the Water Well Construction Rules was <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material M <br />ethod of Placement Interval <br />~77 <br />X0,050 1~ ~~on.l-G ~rok} awd y~i }k~tk ____ Pr±~6ra~C.~~_______ from _ (n00_ feet to - ?8 __ <br />-- - feet <br />ch,ps <br />(oS4~ Ib en.~w~ Bo l[!arv. - U from _ ^'?8_ feet to _-~ ___ <br />feet <br />---------------------------------- --------------------- from ------ feet to -------- feet <br />------- -------------------- -------------------------- from ------- feet to ------- feet <br />Intervals of casing removedlripped in feet from _____ feet to ____ feet <br />I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Please print t <br />h <br />e Signer's Name 8 Title Signatures Date <br />/ <br />~ <br />l I M m _ L oMe~ - - ~--1 %.fMiN1 ~~7/N~-- <br />_tnylionZv1en1a/_~onrdr~w/a~ /~ O')_O(o-D/ <br />It is the responsibility of the well owner to have the well properly plugged and sealed. The Well Construction Contractor is <br />responsible for notifying the owner of this requirement. <br />