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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 hftp://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 to a or <br />MH File Number MH- Hole ID #/Name O ~ J <br />Individual/Company responsible for plugging and sealing the welP <br />NAME(S) S~ Lt2 C S Cy ~ ~ Co w. tt 4 ~ <br />[~ / r o. <br />Mailing Address Po Q aK 6 1 <br />City, St., Zip <br />Phone (~ <br />Well (Hole) Owner: <br />NAME(S) JC ~C. L~t~ f:ls 0. ~ ~ J~ Phone <br />Mailing Address, City, St., Zip <br />ACTUAL WELL LOCATION: County _~ ~'~' n n (~ <br />Property Address, City. St, Zip 3 2~ ~ ~ O ~.`~ "ocarX 53 r ~ 4+,.t r~Q.~n t C V ~ ~ ~3 <br />1/4 of the.$~ 1 /4, Sec. ~, Twp. ~_~ N. or ~ S-, Range ~_~ ~ E. or®w ~ P M. <br />Distance from Section Lines ~~ Ft From ~ N. or ® S., ~OO Ft. From ®E. or 0 W. Line. <br />Subdivision Name /VH Lot ,Block ,Filing/Unit <br />Optional: GPS well location information in UTM format. You must check CPS unit for required settings as folbwsr <br />Format must be UTf.1, zone 12 ~ or zone 13 ~; Units mutt be meters; Datum must be N,'~D83; Unit m_.st be set to true north. <br />Eastino Northing <br />I (we) report the existing well (hole) was plugged and sealed on the date of p' ~ (~ - U ~ for the following reason(s): <br />Cl The well was plugged and sealed as required under Well Permit Number <br />I ~ The well was not in use a~~nnd~e was plulIgged and seal~e~d. (' ~ /~ I ~~ I f n f <br />®Other (please explain) t~10~.. `y~^ CrUe4_L'['~c,t~~-lz Well WAS ~l~.~t y~~P~{! ~~~V~d~, <br />N -~ w~~ ba~-bc f~we~L1 0~~4-~ -o <br />The well was plugged with the following `materials placed at the inaiicated intervals: <br />Amount and Type of Material Method of Plarycement Interval <br />o~,3~ -~f3 Ce.I~.C'~d_ei l^o ti~ -- --tf~Ca... tih~QCJ~ from ~__feet to_ ~~y_feet <br />_ Y 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 plugginC 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 print the Signer's Name & Title Date <br />_ ~Ek~+iS ~ Ctil.°s <br />li !s the responsibility of the well owner to have the ~:velllhcle properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />