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w- <br />FORM STATE OF COLORADO For Office Use only <br />No. <br />GWS-8 OFFICE OF THE STATE ENGINEER <br /> <br />12/96 g18 Centennid 81dp., 1313 Sherman St., Denver, Cobrado 80203 <br /> 03 68 <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />fio Report Pluppinp end Seelinp Wells) <br />PERMIT NUMBER OF PLUGGED WELL <br />1. INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) Hnlnam Inc. <br /> Mailing Address 3500 State HiQitway 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 Hi~_wav X20_ Portland CO 81226 <br /> (Address) (City) (8tatsl <br />(Tip1 <br /> n <br />~_t/4,~) 1/4, Sec.~_Twp.~9 _ ~N. OG.IS., Range 68 ^E. LX.IW. 6'~ P.M <br /> Line <br />Distances from Section Lines 2400 Ft <br />Line <br />100 Ft <br />from ~ E <br />or ®W <br />from ®N <br />~ S <br /> . <br />. <br />. <br />, <br />. <br />. <br />. <br />3. 1 (we), report that an existing wall 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.039617-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 t0 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 poured from 3 feet to 4 feet <br /> bentonite clops (hydrated durins installation) poured into casin>; from 4 feet to 98 feat <br /> Colorado silica sand (8 x 121 poumd into casin>; from 98 "feet to 151 feet <br /> from feet to feet <br /> INTERVALS OF CASING REMOVED/ti1PPED tN FEET from +4 feet fo 3 feet <br /> from feet to feet <br />6. I (we) have read the statemensS made herein and know the cornents thereof, and that they are true to my (our) <br />knowledge. (Pursuant to Section 24-4-104 (1311a) C.R.S., the making of false statements herein constitutes parju <br />in the second de ree and is unishable as a class 1 misdemeanor.] <br />Name/T'nle (Please type or print) Signature Date <br />Tracy Gunn /Quarry Foreman <br />-INFORMATION- his the responsibility of the well owner to have the well properly plugged antl 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 Dhotocopy or word processing means. ~yJ- Z <br />