GENERAL54030

• Permit No: C1982057
• IBM Index Class Name: General Documents
• Doc Date: 10/12/2007
• Doc Name: W24 Series Well Abandment Form
• From: Seneca Coal Company
• To: DRMS
• Permit Index Doc Type: Exploration
• Media Type: D
• Archive: No

Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only
GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
C>12006 [phone] Fax [phone] http://www.water.state.co.us
WELL ABANDONMENT REPORT
Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or
print in black or blue ink. Instructions and plugging standards are on reverse side of form.
Well Permit Number of the well being plugged a 3 K i 6 `t or
MH File Number MH- Hole ID #/Name Ali ~
Iridividual/Companv responsible for plugging and sealing the well
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NAME(S) SE Lt C ~v
/
Mailing Address P~ 13 c~ 6l0
Gity, St ,Zip co 8 16 3

Phone (~~O ) a. 6 '- 5 ~ ~~
Well (Hole) Owner: r
NAME(S) S4.tnt~ GlS 0. ~ tl V ~ Phone ( )
Mailing Address, City, St ,Zip
ACTUAL WELL LOCATION: County _ `~D k ~P. n ((~~ t' nn
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Property Address, City. St, Zip 3 2 S 6 o COt.~~+'~ y IT ociGY ~ 3 +
_~1/4 of thes[- 1/4, Sec. ~, Twp. ~® N. or^ S.. Range ~_~_ ^ E. orb W., ~ P.M.
in
0~ Ft. From ^ N. or ® S., S l Q FL From ~ E. or ^ W. Line.
Distance from Section L
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A
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Subdivision Name I V/t Lot ,Block ,Filing/Unit
Optional: GPS well location Information in UTM format. You must check GPS unit for required settings as follows:
Format must be UTM, zone 12 ~ or zone 13 ~; Units mutt be meters; Datum must be NAD83; Unit must be set to true north.
Fasting Northing
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I (we) report the existing well (hole) was plugged and sealed on the date of _ p' ~ 6 - O r for the following reason{s):
^ The well was plugged and sealed as required under Well Permit Number
I ^ The well was not in use and was plugged and sealed. (r~'''
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Other (please explain)~Oh.
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The well was plugged with the following materials placed at the indicated intervals:
Amount and 3ype of Material Method of Plac
ement Interval
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_I~~~± Ce.~h6h _~ 4dc~~ ___ _ ~ ft ha ~ o__I _cJC _ from ~_ feet to __3~_ feet _
from feet to feet
from feet to feet
Intervals of casing removed/ripped in feet from feet to feet
Report must be signed by person who performed the wel{ plugging work or by the well owner if this person is unknown or not reachable. I
(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
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Signature(s) Please print the Signer's Name & Title
.a.,~ ~ _~~e4..,:s Jv~es
Date
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It is the responsibility of the well owner to have the ~.vell/hole properly plugged and sealed. The Well Construction Contractor
~ is responsible for notifying the owner of this requirement.