2002-12-16_REVISION - M1977344 - Laserfiche WebLink

Home Browse Search

trot Office Use only INEER in St., Denver, Colorado 80203 REPORT II ELL MH- 35582 ~~+-5 FOR PLUGGING ~~l-S .t Co. a~~3z Freme.~fi ~t_~ ~ /Z.O+ ~~erewict y tr'p 8/ 2.Z (o (City) lstate) IZipl ~~~~77II / 9 ^ N. ri.l S., Range !o S ^ E. ®W. 6 ~ P.M. Distances from Section Lines 600 Ft. from ~ N. ®S. Line, / 00 Ft. from ®E. or^ W. Line 3. 1 (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 Well Permit No. MFI-35582 Culall 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 l~pr~ ~ l ~ , 'ks zeoo. 5. The well was plugged with the following materials placed at the indicated intervals:. AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL o~eN ~IG - ~YPA fe be wa,Nes/ from O feet to S9 feet ~ fia.T e~ bew~'o..,~rte Dios brae ~1( from~feetto 79 feet ,approx. /(oo .u.l/e.,s s~ groLL't" -l-rewric from 79 feet to ~z0 feet from feet to feet INTERVALS OF CASING REMOVED/RIPPED IN FEET ~dr~ 1I~ e~{'/ from O feet to ' / 20 feet from feet to feet 6. I (we) have read the statements made herein and know the contents thereof, and that they aze true to my lour) knowledge. [Pursuant to Section 24-4-704 (131(a) C.R.S., the making of false statements herein constitutes perju in the second de tee and is unishable as a class 1 misdemeanor.] Name/Trcle (Please type or print) Sig a Data -INFORMATION- It is the responsibility of the well owner to have ~e well properly plugged and sealed. The Well Construction Contractor is responsible for notifying the well owner of the plugging and sealing requirement. This form may be reproduced by photocopy or word processing means.