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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 />6/2003 (303) 866-3581 Fax (303) 866-3589 <br />WELL ABANDONMENT REPORT <br />Tvpe or print in black ink. <br />Well Permit Number of the well being plugged <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) _ ___ <br /> <br />Mailing Address _____ __ __ <br />City, St. Zip _ <br />_____ <br />___ <br />Phone ( ) _ <br />ACTUAL WELL LOCATION: County <br />Property Address <br />_ <br />(Address) (City) (State) (Zip) <br />___1/4 of the_ 1/4, Sec. _, Twp. ____^ N. or ^ S., Range __ ^ E. or ^ W., _ P.M. <br />Distance from Section Lines Ft. From ^ N. or ^ S., ___ Ft. From ^ E. or ^ W. Line. <br />Subdivision Name __ Lot ,Block _, Filing/Unit <br />I (we) report that an existing well was plugged and sealed for the following reason(s): <br />^ The well was plugged and sealed as required under Well Permit Number <br />^ The well was not in use and was plugged and sealed. <br />^ Other (please explain) _ <br /> <br />The date the well was plugged according to the Water Well Construction Rules was <br />The welt was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />_ _ _ from _ feet to feet <br />_ from feet to _ feet <br />__ from feet to _ feet <br />_ _ from feet to feet <br />Intervals of casing removed/ripped 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 the Signers Name 8 Title Signature(s) Date <br /> <br /> <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 />n~~oc fIIDDI [MG AIT <br />DR <br />T Nf, nRCFRV4T <br />IIC <br />