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:~ <br />FoRMNO. <br />9 STATE OF COLORADO For Otfloe Use only <br /> OFFICE OF THE STATE ENGINEER <br /> 818 CerMnnia! Bldg., 13t3 Sherman SL, Damnr, Colorado 80203 <br /> (303) 8G6-JSBI <br />E OR PRINT IN BLACK INK <br />WELL ABANDONMENT RE~'O~' <br />71'b <br />ABANDONm WELL NUMBER IF REGtSTt~l]) <br />~ <br />1. INDMDUAUCOMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) <br /> <br /> Mailing Address <br /> city, sL zp U <br /> Phone (C(?b } - <br />2 ACTUAL WELL LOCATION: COUNTY b <br /> PROPERTY ADDRESS <br /> (P.ddrsss) (chyl fs~l lea) <br /> r~~ 1/4 _~t/4, Sec.~~ Twp.~_ ®N. ^ 5., Range ^ E <br />® <br />W. ~_P.M. <br /> ~ <br />{ <br />Distances from Section Lines _3/ay FL from ®N. ^ S, Line, _ r//L1 FL from LC~-E or 0 W. Line. <br />3. I (we}, report that an existing well was plugged and abandoned for the following reason(s): <br /> (The well was plugged and abandoned a~ required under the condRions of <br />° <br /> YY <br />YC apPn~val of Well Penn2 No. 1 <br /> The well was not in use and was abandoned. <br /> Other (please explain) <br /> <br />4, The well was plugged and abandoned according to the Water Well Construction <br /> and Pump Irvtallation Rules on Q3~/S . 19 Q~. <br />5. The well was plugged with the following materials placed at the indipied intervals: <br /> AMO AND TYPE OF hfATEAIAL METHOD OF PLACEMENT INTERVAL <br /> 3~ 1~„)n C7Yi-itl~I 0 from~Q„~eetto~_(}eet <br /> ~Y' ~ Q G~L~,~~~et to ~O~eet <br /> nn <br />3 ~~r^rr ~,t~ (~~A rJt ~, ~l~ r~ O~ from~~feet to ~0~#eet <br /> ~~,~ l~p~ }^p ~Q from U feet to /feet <br /> INTERVALS OF CASING REMOVED/RIPPED IN FEET from feet to feet <br /> from feet to feet <br />6. I (we) have read the statemerns made herein and know the contents thereof, and that they are true to my (our) <br /> knowledge. [Pursuant to Section 2a-4-104. (13)(a) C.A.S., the making of false staremerrts herein ccnstrtutes perjury <br /> in the second degree and is punishable as a class 1 misdemeanor,] <br />e/Trtle (Please type or prim) Ig afar '~ Date <br />ACT7J 2 <br />/ <br />~ ~ <br />/ <br />~ <br />~• l,-/2E~7Ur2 / r• rn ~ / <br />i iv / ~ i <br />-INFORMATION- I[ is the resporLSibi Ily of the well owner to have the well property plugged and abandoned. <br />The well construciort contractor is responsible for notifying the welt owner of the plugging and abandonment requiremer <br />This form may be reproduced by photocopy or word processing means. <br />