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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER ' ror Of£ce Use Only <br />GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 I <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 ~(I 6 3 or <br />MH File Number MH- Hole fD #/Name W SC~y <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) S~ C Cu ~. ~ ~o wx q <br />Mailing Address Po Qo)C 6 1 <br />co 8 16 3 <br />City, St., Zip <br /> <br />c <br />Phone (~O,) a 6 - S ~ ~~ - <br />Well (Hole) Owner: II <br />__ <br />NAME(S) Sit 1M~ CtS 0. W U J~ Phone ( ) <br />Mailing Address, City, St., Zip <br />ACTUAL WELL LOCATION: County IC o t+ ~' <br />C <br />~ <br />2 <br />Q <br />{ <br />p.v. t C u ~ j 63 <br />Property Address, City, St, Zip 3 <br />5 6 o Co~..~.`~ ~1 R o~~Q 53 f <br />n~.t t <br />~~ 7/4 of theSC 1/4, Sea ~, Twp. ~~® N. orb S., Range ~ ~ E. or~(W ~ P M. <br />X00 Ft. From ^ N. or ~ S.. ~ a O Ft. From ~ E. or [] W. Line. <br />Distance from Section L <br />in <br />es <br />t <br />A <br />~ <br />Subdivision Name I 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 he UTM, zone 12 ~ or zone 13 C7 ; Units mu: t be meters; Datum must be NAD83; Unit must be set to true north. <br />Fasting Northing <br />I (we) report the existing well (hole) was plugged and sealed on the date of g' ~ (> ' ~ _] for the following reason(s): <br />~ The well was plugged and sealed as required under Well Permit Number <br />was plugged and sealed. <br />The well was not in use a <br />n <br />d <br />,~ <br />' <br />A <br />(('' //~~ II ~'~~ I `' <br />®Other (please explain) fVlOh~a ~V~` WaL~ 'T'~t.[ec~ V"Ql` (N a.S p~~+~t <br />~ a-~O'd7. <br />`_ <br />~e~. wgs ba~l,c F.1[PCSZ weel,L o~ 9-~ -D <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 />p <br />~,~~3_C2v~rlC.K~ VO K~ l^!++ 2~ from ~ feet to 3 1 feet <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 i( 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 />Sign ture(s) Please print the Signer's Name & Title Date <br />\ <br />c~-J ~e~~~s J ohes <br /> _~ ~~~ ~~ ~ 5d- io - a -0~7 <br /> <br />I It is the responsibility of the well owner to have the vaell/hole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />