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GENERAL38269
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Entry Properties
Last modified
8/24/2016 7:58:06 PM
Creation date
11/23/2007 9:33:44 AM
Metadata
Fields
Template:
DRMS Permit Index
Permit No
C1982057
IBM Index Class Name
General Documents
Doc Date
10/18/2007
Doc Name
W24 Series Well Abandonment Forms
From
Seneca Coal Company
To
DRMS
Permit Index Doc Type
Exploration
Media Type
D
Archive
No
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Forrn No. STATE OF COLORADO, OFFICE OF THE STATE ENGfNEER For Office Use Only <br />GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />6/2006 (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or <br />print in black or blue ink. Instructions and plugging standards are on reverse side of form. <br />Well Permit Number of the well being plugged a 3 y ~ 6 5 or <br />MH File Number MH- Hole ID #/Name (.U W C,'1 <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) .St tn~ C S ~ <br />u ~. 1 Co ~ _T q 4 l.~ <br />/ <br />Mailing Address (-~ QojC 6 1 <br />city, st., zip CO g 16 3 <br />Phone (~O ) a. 6 - 5 ~ ~ <br />Well (Hole) Owner: f <br />NAME(S) 5Q.1ht~ elS 0. IA cl J ~ Phone ( ) <br />Mailing Address, City, St., Zip <br />ACTUAL WELL LOCATION: County ~ o t,.'~/~' n ~t (~ <br />~ <br />~ <br />Q <br />O ~ ~ (,3 <br />aa.t ~ <br />Property Address, City, St, Zip 3 2 5 6 o COkw'~ ti R ogr~ 53 t <br />o.M ~ <br />~_1/4 of thes~ 1/4, Sec- ~, Twp. r ~ N. orb S.. Range ~ ~ E. or® W., ~ P.M. _ <br />in <br />es ~~ Ft. From Q N. or ® S.. 6U Ft. From ®E or ~ W, Line. <br />Distance from Section L <br />A <br />~ <br />Subdivision Name 1 V~ Lot ,Block ,Filing/Unit <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br />Format must be UTM, zone 12 ^ or zone 13 ~; Units mutt be meters; Datum must be NAD83; Unit must be set to true north. <br />Fasting Northing <br />f (we) report the existing well {hole) was plugged and sealed on the date of g' ~ 6 - O ~ for the following reason(s): <br />0 The well was plugged and sealed as required under Well Permit Number <br />0 The well was not in use and was plugged and sealed. <br />(('' //~~ 11''11 f `' <br />®Other (please explain) ~Oh~. w'z` We. L~ T4.1'e t.L Wel~ W0.5 nl4y ~l~ a_'6-~7. <br />try was loa~l,~ ~~ecS~weell o~ s9-~`L_ 01 <br />The well was plugged with the following materials placed at the intlicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />~.3Cas.}3eewer.~ ~~ow~ __ __ /1~!"^~1e~ _ from ~ feetto_s~v-feet <br />_-(` 1 <br />from feet to feet <br />from feet to feet <br />Intervals of casing removed/ripped in feet from feet to feet <br />Report must be signed by person who performed the well plugging work or by the well owner if [his person is unknown or not reachable. I <br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Signature(s) Please print the Signer's Name 8 Title Date <br /> ,~, <br /> <br /> ~.C,. a l U i SCf' ~ ~- a-~ 1 <br /> <br />It is the responsibility of the well owner to have the well/hole <br />is responsible for notifying the owner of this requirement. <br />properly plugged and sealed. The Well Construction Contractor <br />
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