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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 />Tint in black or blue ink. Instructions and lu in standards are on reverse side of form. <br />Well Permit Number of the well being plugged Well was Not Permitted <br />or MH File Number MH- Hole ID #/Name 892W <br />Individual/Company responsible for plugging and seal)ng the we)I: <br />NAME(S) WWC Engineering <br />Mailing Address 611 Skyline Road <br />City, St., Zip Laramie. WY 82070 <br />Phonej307)742-0031 <br />Well (Hole) Owner: <br />NAME(S) The Pittsburg and Midway Coal Mining Co. Phone (303) 930-4013 <br />Mailing Address, City, St., Zip 116 Inverness Drive East. Suite 207. Englewood. CO. 80112 <br />ACTUAL WELL LOCATION: County Routt <br />Property Address, City, St, Zip 4 Miles Northwest of Oak Creek. Colorado <br />SW 1/4 of the SW 1/4, Sec. 31, Twp. 5 N. Range 85 W., 6 P.M. <br />Distance from Section Lines 208.77 Ft. From S. Line, 76_50 Ft. From W. Line. <br />Subdivision Name N/~ Lot N/A, Block N/A, Filing/Unit N/A <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br />UTM zone 13 Units Meters Datum NAD83 <br />Eastin 332269.902 Northin 4467384.987 <br />I (we) report the existing well (hole) was plugged and sealed on the date of 5/18/07 for the following reason(s): <br />The well was plugged and sealed as required under We(I Permit Number N/A. <br />The well was not in use and was plugged and sealed. <br />X Other (please explain) Monitoring was discontinued in 2007 in accordance with TR-47 of PN C-80-001. <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />Black Hills Bentonite ULTRA Grout. 6 Gallons Funnel Downhole from 30.29 ft-bgs to 15.8 ft-bgs <br />ACC Volclav/Pure Gold Y," Bentonite Tablets..5 Gallons Funnel Downhole from 15.8 ft-bas to 1.7 ft-bas <br />Intervals of casin removedlri ed in feet from 1 H-gas to 1.7 ft-b s <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. <br />I we have read the statements made herein, know the wntents thereof, and that the are true tom our knowled e. <br />Signal e s Please print the Signer's Name & Title Date <br /> TSr~ot .SM^M~.RS , As~c,rtt£. G~icsisr <br /> slaslo~- <br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction <br />Contractor is res onsible for noti in the owner of this re uirement. <br />