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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 ar blue ink. Instructions and plugging standards are on reverse side of form. <br />Well Permit Number of the well being plugged a 3 K i 6 6 or <br />MH File Number MH- Hole ID #/Name W W e (~ ~ <br />Individual/Company responsible for plugging and sealing the well <br />NAME(S) 5~ Lt G Cu 0. ~ \ o ~ 0. M <br />Mailing Address I-~ QajC O 1 <br />CO 8 16 3 <br />City, St., Zip - <br /> <br />c <br />Phone (9~0 ) a 6 - J ~ 0 <br />Well (Hole) Owner: <br />NAME(S) S~t1M.~ ~lS a ~ U V ~ Phone ( ) <br />Mailing Address, City, St., Zip <br />ACTUAL WELL LOCATION: County R o ~ ~/~ n (~ (~ / (`~ <br />3 2 5 6 0 <br />~ V ~ ~ <br />53 <br />~ <br />3 - <br />Property Address, City, St, Zip <br />1,~Ol~y._~ 1` ocaCX <br />0.~ CX4!~~ ~ <br />~ <br />b <br />1 <br />_~1/4 of thes~ 1/4, Sec. ~, Twp. ~ ®N. or ~ S., Range ~ ~ ~ E. or® W., ~ P. M. <br />Distance from Section Lines _1 ~~ Ft. From ~ N. or ~ 5., ~ U Ft. From ~ E. or ~ W. Line. <br />Subdivision Name NA 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 mint be meters; Datum must be NAD83; Unit must be set to true north. <br />Fasting Northing <br />i -'1 <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 />0 The well was plugged and sealed as required under Well Permit Number <br />^ The well was not in use a <br />nd was plugged and sealed. ((-' ((~~ <br />r ( <br />~~nn <br />' <br />! ~~ <br />®Other (please explain) r~l ~h. lug` WeI,~ T4.''e c-~. Wedl W0.S ~k ~ b- 6~ e~7. <br />Pti ww-~ ba~lt ~:I(PCS2 wee l.( o~ !9-~ -O <br />The well was plugged wish the following materials placed at the indicated intervals: <br />A~m1ount and Type of Materiat(l ~ ,,QQ Method of Placement Interval <br />or . 3 ~ ~~_ G2fMCwV_~ ~/'O!W~ ~KM+~_~_ _ from _ ~___ feet to _._5 p~ feet I <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 welt 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 />I <br /> <br />Signature(s) _ _ <br />Please print the Signer's Name & Title _ _ <br />Date <br /> !' ~t.~ <br />h i5 ~oylos _ <br /> (( <br />CC c~C~o o~iS~ C7 ~~--~ Z <br /> V <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 />