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Form STATE OF COLORADO For Office Use Only <br />No. 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 rint in black ink. <br />Well Permit Number of the well being plugged Nn <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 />Clty, St. Zip Pagosa Springs, CO 81147 <br /> <br />Phone (970 731-2945 <br />ACTUAL WELL LOCATION: County /+rchuleta <br />Pfopefty Address 5 miles south of junction HWY 160 and HWY 151 Colorado <br />(Address) (City) (State) (Zip) <br />NW SE 30 34 ~ 4 ~/ 107 <br />1/4 <br />f th <br />T <br />E <br />M <br />1/4 <br />S <br />~N <br />R <br />~ W <br />P <br />^$ <br />. or <br />. or <br />. <br />o <br />e _ <br />, <br />ec. _, <br />wp. _ <br />ange _ <br />., _ <br />. <br />., <br />2300 <br />3300 <br />^ <br />~ <br />~ <br />^ <br />g„ <br />Distance from Section Lines <br />N. or <br />Ft. From <br />W. Line. <br />Ft. From <br />E. or <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 antl bond release. <br />Other (please explain) <br />Monitoring Well W-5 <br /> <br />The date the well was plugged according to the Water Well Construction Rules was May 2003 <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and TvPe of Material Method of Placement Interval <br />Cement cap from 4.o feet to s.o feet <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 feettofeet <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 />o Date <br />Jerry Koblitz ~ ~ <br /> <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 notif in the owner of this re uirement. <br />