Laserfiche WebLink
Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER 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 ~ t 6 ~~ or <br />MH File Number MH- Hole ID #/Name W W~ V 'ot ~~ <br />Individual/Company responsible for plugging and sealing the well: <br />1 Co 1~-i R <br />NAME(S) St? Lt C ~u <br />ti <br />/ <br />-r <br />Mailing Address Po QoX 6 1 <br />City, st., Zip co ~ 16 3 <br /> <br />Phone (quo) 2. 6 - 5 2 o~j - <br />Well (Hole) Owner: r <br />NAME(S) S~CC..t~t ~' `lS 0.1tpdJ~ Phone ( ) <br />Mailing Address, City, St, Zip <br />ACTUAL WELL LOCATION: County o t1 <br />C <br />( <br />Property Address, City, St, Zip ~ 2_ S 1~ ~ I..Ok~+`~ 4 1~ og~ S 3 I r~ q a.t r,~¢,.v~ t ~ O ~ ~ 63 <br />~_1/4 of thes~ 1/4, Sec. ~, Twp. __~ ~ N. or~~ .S Range $~ 0 E. orb W., ~ P.M. <br />Distance from Section L <br />in <br />~~~ Ft. From ^ N. or ® S., S u ~ Ft. From [~ E. or ~ W. Line. <br />es <br />t <br />A <br />~ <br />Subdivision Name 1 V/t 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 n; Units mint be meters; Datum must be NAD83; Unit must be set to true north. <br />Fasting Northing <br />i <br />I (we) report the existing well (hole) was plugged and sealed on the date of g' ~6 - O ~ for the following reason(s): <br />~ The well was plugged and sealed as required under Well Permit Number <br />nd was pl <br />ugged and sealed. <br />I ~ The well was not in use a <br />(' /~ / ., `' <br />1 <br />~'n <br />~P~ D~(6'U~. <br />®Other (please explain) Ir'lOh. \y~^ WaLI T~l~~e~-l''. WQ~~ W0.S ~yy <br />w <br />i trE'K__4~0.5 bawl.( f~edZ weQl.1 0~ !~-~ -O <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />~~~{3 CQ.~yQy e, Ma c~~ __ _ ~ (.L tn. r QJL _ from ~_ feet to _ 3~_ _ feet <br />-V_ <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 this 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 & Title Date <br />J -' <br />.a..~--~ ~, e a...: s J o ~e S <br /> <br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />