2002-12-16_REVISION - M1977344 - Laserfiche WebLink

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,VVwy ~ ~ FORM STATE OF COLORADO For Offioe Uss only No. C'W~ OFFICE OF THE STATE ENGINEER 12/86 818 Centennial Bldp„ 1313 Shsrmen St., Denver, Colorado 80203 3 8 TYPE OR PRINT IN BLACK INK WELL ABANDONMENT REPORT fro Naport fMuppinp and Sealing Wells) PERMIT NUMBER OF PLUGGED WELL 039618-M 1. ~1DIVIDUAUCOMPANY RESPONSIBLE FOR PLUGGING NAME(S) Hohlam Inc. Mailing Address 3500 State Highway 120 City, St. Zipp °re~• Phone l 71 ) x 2. ACTUAL WELL LOCATION: COUNTY Fremont PROPERTY ADDRESS 3500 State Highway 120, Portland, CO 81226 IAddreae) ]City] ]State] lZipl SE t /4 ~ 1 /4, Sec. 17 Twp. 19 ^ N. ®S., Range 68 ^ E. 0 W. 6~ P,M 150 Ft Distances from Section Lines 2300 Ft Line from ®E or^ W Line from ®N ^ S , . . . , . . 3. I (we), report that an existing well was plugged and sealed for the following reason(s): The well was plugged and sealed as required under the conditions of approval of Wel! Permit No. 039618-M The well was not in use and was plugged and sealed. Other (please explain) 4. The well was plugged and sealed according to the Water Well Construction Rules on Apn128 , 18 99 5 The wall was plugged with the following materials placed at the indicated intervals: AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL cement grout 1?0~ from 3 • feet to 4 feet bentonite chips (hydrated during installation) poured into casing from 4 feet to 112 feet Colorado•silica sand (8 x 12) lm~ into casing from 112 feet to 159 feet from feet to feet INTERVALS OF CASING REMOVED/RIPPED IN FEET from +4 feet to 3 feet from feet to feet 6. I Iwe) have read the statements made herein and know the convents thereof, and that they are true to my (our] knowledge. [Pursuant to Section 24-4-104 (131(a- C.R.S., the making of false statemer~ herein constitutes perju in the second de ree and is unishable as a class 1 misdemeanor.] Name/l'itle (Please type or prim) Signature Date Tracy Gunn /.Quarry Foreman --INFORMATION- )t is the responsibility of the well owner to have the wall property plugged and sealed. The Well Construction Comrector is responsible for notifying the well owner of the plugging and sealing requirement. Thies form may he reproduced by ohotocoov or word orocessinc means. M bJ ~ 7,