Laserfiche WebLink
wi W - -r <br />'FORM STATE OF COLORADO For Office Uss only <br />No. <br />cws-e OFFICE OF THE STATE ENGINEER <br />72!96 878 Centennid Bldp., 1313 Sherman St., Denver, Colorado 80203 <br /> 3 683 8 <br />TYPE OR PRINT IN BLACK INK <br />WELL ABANDONMENT REPORT <br />(To Report Pluppinp and Sedinp Wells) <br />PERMIT NUMBER OF PLUGGED WELL 039619-M <br />1. INDIVIDUAUCOMPANY RESPONSIBLE FOR PLUGGING <br /> NAMElS1 Holnam Inc. <br /> Mailing Address 3500 State Highway 120 <br /> City, St. Zip Florence, CO 81226 <br /> Phone ( ~ 19) 784-6325 x <br />2. ACTUAL WELL LOCATION: COUNTY Fremont. <br /> PROPERTY ADDRESS 3500 State Highway 120, Portland, CO 81226 <br /> (Address) (City) (State) (Zips <br /> SE 1 /4 ~ 1 /4, Sec. 17 Twp. 19 ^ N. ®S., Range 68 ^ E. ~ W. 6~ P.M <br /> 300 Ft <br />Distances from Section Lines 2250 Ft <br />from ®E <br />or ~ W <br />Line <br />from ®N <br />~ S <br />Line <br /> , <br />. <br />. <br />, <br />. <br />. <br />. <br />3. 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 the conditions of <br /> approval of Well Permit No. 039619-M <br /> The well was not in use and was plugged and sealed. <br /> Other (please exRlain) <br /> <br />4. The wait was plugged and sealed according to the Water Welt Construction <br /> Rules on April 28 ~ g 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 grout 1?0~ from 3 feet to 4 feet <br /> bentonite clops (hydrated during installation) poured into casing from 4 feet to I09 feet <br /> Colorado silica sand (8 x 12) ~ poured into casing from 109 feet to 168 feet <br /> from feet to feet <br /> INTERVALS OF CASING REMOVED/RIPPED IN FEET from ~ feet to 3 feet <br /> from feet to feet <br />6. I (we) have read the statements made herein and know the contents thereof, and that they are true m my tour) <br />knowledge. [Pursuant to Section 24-4-104 (1311a) C.R.S., the making of false statements herein constitutes pery'u <br />in the second de nee and is unishable as a lass 1 misdemeanor.] <br />Name/T'rtle (Please type or print) Signature Date <br />. ...Tracy Crunn /Quarry Foreman <br />-INFORMATION- his the responsibil"ltY of the well owner to have the well properly plugged and sealed. The Well <br />Construction Contractor is responsible for notdying the well owner of the plugging and sealing requirement. <br />TMi~ inn... ,nom., tin rnnrn,inrnrl 6., n6nfnrnnv nr worn( nrnroccinn mP9nc ~ .. i _. d <br /> <br />