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Form STATE OF COLORADO For OfSce Use Only <br />tdo. OFFICE OF THE STATE ENGINEER <br />GWS-09 g21 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />2/2004 303 866-3581 Fax 303 866-3589 <br />WELL ABANDONMENT REPORT <br />T e or tint in black ink. <br />Well Permit Number of the well being plugged N^ <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) Elk River Construction <br /> <br />Mailing Address 700D Honey Bee Place <br />City, St. Zip Paposa Springs, CO 81147 <br /> <br />Phone (970 731-2945 <br />ACTUAL WELL LOCATION: County /+rchuleta <br />Property AddreSS 5 miles south ofjunction HVW 160 and HWY 151 Colorado <br />(Address) (City) (State) (tip) <br />NW SE 30 34 ~ 4 ~ 109 <br />^ <br />^ <br />^ <br />1/4 of the _1/4, Sec. _, Twp. _ <br />N. or <br />$., Range _ E. or <br />W., _ P.M. <br />za5o <br />~ <br />2450 <br />^ <br />~ <br />~ <br />g„ <br />Distance from Section Lines <br />Ft. From <br />N. or <br />Ft. From <br />E. or <br />W. Line. <br />Subdivision Name Lot ,Block, Filing/Unit <br />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 Well Permit Number <br />The well was not in use and was plugged and sealed. <br />/ The well was plugged and sealed as part of the Chimney Rock Mine closure and band release. <br />Other (please explain) <br />Monitoring Well W-9 <br /> <br />The date the well was plugged according to the Water Well Construction Rules was April zoos <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Tvoe of Material Method of Placement Interval <br />Bentonite pellets Hydrated with water from 5'0 feet to 140.0 feet <br /> <br />4. <br />Cement cap <br />from feet to feet <br />from _ feet to _ feet <br />from _ feet to feet <br />o a.o <br />Intervals of casing removed/ripped in feet from feet to feet <br />I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Please print the Signer's Name & Title Sign refs) Date <br />Jerry Koblitz ~ q ~ <br />Project Manager 12/8/04 <br /> <br />It is the responsibility of the well owner to have the well properly plugged and sealed. The Well Construction Contractor is <br />res onsible for noti in the owner of this re uirement. <br />