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FORM STATE OF COLORADO <br />No OFFICE OF THE STATE ENGINEER <br />Gw5-9 glg Centennial Bldg., 1313 Sherman St.. Denver. Colorado 80203 <br />12/95 (307)866-3581 <br />For Off¢e Use Only <br />Approval No GWS9-9ti-OB <br />WELL ABANDONMENT REPORT <br />(To Report Plugging and Sealing Wells) <br />PERMIT NUMBER OF PLUGGED WELL Hole No. LC-4 <br />INDIVIDUAL/COMPANY RESPONSIBLE FOR PLUGGING <br />NAME: Monteomerv Watson Mining Grouo <br />Mailing Address: P O Box 774018 <br />City. St., Zip: Steamboat Sorines CO 80477 <br />Phone: 970/879-6260 <br />COUNTY: <br />PROPERTY ADDRESS: Havden Gulch Mine. Routt Countv Road 53 <br />SE I/4 SW I/4, Sec. 30 Twp. 5 ®N. ~ S., Range 88 ~ E. ® W <br />Ft. from ~ N. or ~ S. Line, <br />P.M. <br />Ft. from ~ E. or ~ W. Line. <br />We report that an existing well was <br />reason (s): <br />~ The well was plugged and sealed as required under the conditions of approval of Well Permit No. <br />~ The well was not in use and was plugged and sealed. /~ n ~] ~//J / ~/ /~ <br />®Other(pleaseexplain) Ca.~.vrwC~+«rler~.yt.~a~~t_~~~+w^~,P~'~~:/w~J 0~..~r~/p~r ~r.cpry~ •~ ty~rye <br />The well was plugged and sealed according to [he Water Well Conshvction and Pump Installation Rules on October 6. 1998. <br />was <br />AMOUNT.4ND TYPE OF MATERIAL METHOD OF PLACEMENT <br />4 bags - cementhentonite grout tremie from 0 feet to 1 19 feet. <br /> from feet to feet <br /> from feet to feet. <br /> from feet to feet. <br /> from feet to feet. <br /> from feet to feet. <br />INTERVALS OF CASING REMOVED/RIPPED IN FEET from 0 feet to 2 feet. <br />Cut ofF 2" PVC and G" steel protective casing, 0' - 2'. <br />I have read the statements made herein and know the contents thereof, and that they are true to my knowledge. (Pursuant to Section <br />24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second degree and is punishable as a class I <br />misdemeanor.) <br />TIM H[MES,General Manager ~_ Dale: 10/13/98 <br />Himes Drilling Company, Inc. <br />?390 Hwy 6 & 50. Grand Jct CO 81505 ~~~"t <br />970/242-8893 / ' <br />fNFORMATION - It is the responsibility of the well owner to have the well properly plugged and sealed. The well construction <br />contractor is responsible for notifying the well owner of the plugging and abandonment requirements. This form may be reproduced <br />by photocopy or word processing means. <br />