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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 ~ ~ 6 a or <br />MH File Number MH- Hole ID #/Name O ~ <br />Individual/Company responsible for plugginq and sealing the well: <br />NAMES} 52 k C Cv ~+ ~ ~o tM q <br />Mailing Address Po Qoj~ 6 1 <br />City, St., Zip c CO 8 16 3 <br />Phone (q70 ) a ~7 - J ~ o~ <br />Well (Hole) Owner: <br />NAME(S) cS~t.1~.t~ GAS r..~~~V~- Phone ( ) <br />I Mailing Address, City, St., Zip <br />f ACTUAL WELL LOCATION: County_~~'~' <br />Property Address, City, St, Zip ~ z S 6 ~ COr..~`I ~{ R o4rQ 5 ~ r ~ qa{ e,Qo..~. t C o ~ ~ 63 C( <br />I ~- <br />i N~_1/4 of thes[- 1/4, Sec. a~. Twp. ~,~ N. orb S_, Range ~_~ ~ E. orb W., ~ P.M. <br />Distance from Section LAin~est ~~~ FL From 0 N. or ® S., Soo Ft. From ®E. or ~ W. Line. <br />Subdivision Name 1 V/i Lot ,Block ,Filing/Unit <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br />~-ormat must be UTM, zone 12 ~ or zone 13 ~; Units mvrt be meters; Datum must be NAD83; Unit must be set to true north <br />Fasting Northing p --f <br />1 (we} report the existing well (hole) was plugged and seated on the date of b ~ 1 ~ ~ t~ ! for the following reason(sl: <br />CI The well was plugged and sealed as required under Well Permit Number <br />~ The well was not in use and was plugged and sealed. //~~ 11 b f <br />®Other lease explain h~ ~ ~ ~~ ~ tJ[ Lt r ~ eQ b ~l7-U~ , <br />(P )~10~, vim` We- ~c ~ WQ WAS ~+~{~ <br />~ye-~ w~~ ba~lc ; I QcSZ wee.l,L o~ !9-~ - 01 <br />The well was plugged with the following materials placed at the indicated intervals: <br />A~^mlount//antd-Type of Material 1 Method of PlaPnlcement Interval <br />of • 3 b "F~ CeM+Cv~C,_~I!O ti~' _ _ ,~C.~~h p Q.cK from ~ _ _ feet fo __ ~~_ feet <br />I~ from Feet to feet <br />from feet to feet <br />Intervals of casing removed/ripped in feet <br />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 />Sign tare(s) Please prink the Sigrrner's Name & Title Date <br />~4.~~ ~ eM to C S y ~ ~L°S <br />F~u~U~l~,u;.~ct lD-a-o <br />It is the responsibility of the well owner to have the •.vell/hcle properly plugged and sealed. The Well Construction Contractor <br />Is responsible for notifying the owner of this requirement. <br />