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REC <br />nEC 0 ~ 2004 <br />Form STATE OF COLORADO For Office Use Only <br />T~O OFFICE OF THE STATE ENGINEER DiuisionotMineralsandGea <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 riot in black ink. <br />Well Permit Number of the well being plugged NA <br />Individual/Comoanv responsible for plugging and sealing the well: <br />NAME(S) Elk River Construction <br /> <br />Mailing AddreSS 7000 Honey Bee Place <br />Clty, St. Zip Pagosa Springs, CO 81147 <br /> <br />Phone 970 731-2945 <br />ACTUAL WELL LOCATION: County Archuleta <br />Property Address 5 miles south ofjunclion HWY 160 and HWY 151 Colorado <br />(Address) (City) (State) (Zip) <br />NW SE 30 34 ~ 4 ~ 107 <br />N <br />R <br />1/4 <br />f th <br />1/4 <br />S <br />T <br />^S <br />E <br />~ W <br />P <br />M <br />. or <br />ange _ <br />o <br />e _ <br />, <br />ec. _, <br />wp. _ <br />., <br />. or <br />., _ <br />. <br />. <br />150o <br />3zoo <br />~ <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 Lqt ,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 Rack Mine closure and bond release. <br />Other (please explain) <br />Monitoring Well A-1 <br /> <br />The date the well was plugged according to the Water Well Construction Rules was Mav zoo3 <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Tvae of Material Method of Placement Interval <br />Bentonite Pellets Hydrated with Water from 2'0 feet to 7~0 feet <br />Craded over from o feet to z 0 feet <br />from feet to feet <br />from feet to _ feet <br />0 7.0 <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) <br />1 <br />. Date <br />Jerry Koblitz ~ <br />~ ~ <br />7t p <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 />logy <br />