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~- <br />Form No. - <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />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 ~r r 6 5 or <br />MH File Number MH- Hole ID #/Name W W Ca L <br />gginq and sealing the well: <br />Iridividual/Company responsible for plu <br />g <br />NAME(S) -SE C ~v'~ \ Cob.1 Q4 <br />Mailing Address Po Qox ~ ~ O <br />C~ O ~ ~ 3 <br />Gity, St., Zip <br /> <br />C <br />Phone (~~O ) a. 6 ' .J ~ 0~ <br />Well (Hole) Owner: <br />NAME(S) S~tV-t.~ ~lS 0.~C)J~ Phone { ) <br />Mailing Address, City, St., Zip <br />~7 <br />ACTUAL WELL LOCATION: County I[ o t„~p~ t~ (~ <br />~ <br />4a.( ~QM ~ O ~ ~ 63 <br />Property Address, City, St, Zip 3 2 5 6 o I„Ok~.`~ y 1~ oq~ 5 ~ r <br />tY ~ t/4 of then[ 1/4, Sec. ~, 7wp. ~__® N. or ~ 5., Range ~_~_ Q E. or®W _~ MP <br />Distance from Section Lines ~~C~O FL From ~ N. or ® S., EiC~ Ft. From ®E. or ~ W. Line. <br />+ Subdivision Name N~ 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 C7; Units mutt be meters; Datum must be NAD83; Unii must be set to true north. <br />Fasting Northing <br />O <br />I (we) report the existing well (hole) was plugged and sealed on the date of p ' ~ 6 - O ~ for the following reason(s): <br />~ The well was plugged and sealed as required under Well Permit Number <br />gged and sealed. <br />I ~ The well was not in use and was plu <br />(('~ <br />1 <br />Other (please explain) fYI O~..~u~` WeI,~ '["~.,'2~ wed WAS p14c{q,o ~'6'U7. <br />i ~r~c _,~a.t bay- :I wee o 9-~ - o <br />The well was plugged with the following materials placed at the indicatetl intervals: <br />Amount and Type of Material Method of Pl <br />acement Interval <br />a <br />a .3G s~~3 e 2we~+'~ V~ok~ _ K r"" eJC from ~ feet to _ s_~ feet i <br />------ -A - -~ <br />~ <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 readable. I <br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />~ <br />Signature(s) Please print the Signer's Name & Title Date <br /> ~~ <br />~.~.p.,-~-~ e_t..~. s J d ,..e <br /> ~~~~~5~- ~o-a-~~ <br /> <br />It is the responsibility of the well owner to have the vdell/hole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this reyuirernent. _, <br />