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/riw-1 <br />FORM STATE OF COLORADO ~ For offtce use only <br />No. <br />GWS-8 OFFICE OF THE STATE ENGINEER <br /> <br />12186 81a Centennid Bldp„ 1313 Sherman St., Denver, Colorado 80203 <br /> ea <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />(To Report Pluppinp end Sadinp Wills) <br />PERMIT NUMBER OF PLUGGED WELL 039616-M <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) Holnam Inc. <br /> Mailing Address 3500 State Hifhway 120 <br /> City, St. Zip Florence, CO 81226 <br /> phone ( 719) 784-6325 x402 <br />2. ACTUAL WELL LOCATION: COUNTY Fremont <br /> PROPERTY ADDRESS 3500 State Hiehway 120. Portland. CO 81226 <br /> ICityl IStatsl (Z~p1 <br />IAddresal <br /> L~I <br />~}~1 /4, rn~v 1 /4, Sec. 16 Twp. 19 ^N. Uu S., Range 68 ^ E. ®W. 6'" P.M <br /> Djstances from Section Lines 2400 Ft. from ®N. ^ S. Line, 450 Ft. from ~ E. or ®W. Line <br />3. I (wel, report that an existing well was plugged and sealed for the following reason(s): <br /> ® The well was plugged and sealed as required under the conditions of <br /> approval of Well permit No. 034616-M <br /> The well was not in use and was plugged and sealed. <br /> ~, Other (Please .explain) _ _ _ <br /> <br />4. The well was plugged and sealed according to the Water Well Construction <br /> Rules on Apri128 , 19 99 . <br />5. The well was plugged with the following materials placed at the indicated intervals: <br /> AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL <br /> cement,;rout pouted from 3 feet to 6 feet <br /> bentonite chips (hydrated during installation) Wowed into casing from 6 feet to 97 feet <br /> Colorado silica sand (8 x 12) powed into casing from 97 feet to 145 feet <br /> from feet to feet <br /> INTERVALS OF CASING REMOVEO/RIPPED IN FEET from +4 feet to 3 feet <br /> from feet to feet <br />6. I (wet have read the statements made herein and know the contents thereof, and that they are true to my (our) <br />knowledge. [Pursuant to Section 24-4-104 (1311a1 C.R.S., the making of false statemenrts herein constitutes pery' <br />in the second d ree and is nishable as a class 1 misdemeanor.l <br />Neme/Trtle (Please type or print) Signature Date <br />Tracy Gunn /Quarry Foreman <br />-INFORMATION- It is the responsibility of the welt owner to have the well property plugged and sealed. The Well <br />Construction Contractor is responsible for notifying the well owner of the plugging and sealing requirement. <br />This form may be reproduced by photocopy or word processing means. M~- I <br />