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STATE OF COLORADO ~ ~« oraa u~+ ~r <br />~~ I OFFlCE OF THE STATE ETIGINEER <br />a18 CwmiN eldp.. 1319 snrnw at. onrK Calando s02w <br />PWl eesasst <br />~E OR I~FiYQi fN 8Lf1ClC QriC <br />WELL ABANDONMENT REPORT <br />ABANDONED WELL NUMBER lF RC-GfSTERED }~~T Q . 5 - y l S <br />NAMEIs) . Wl e s ~- E3 l K. Yn ~ ru_° Wl pQn J I.LC_. <br />MaTrg Address . P o box 5 q ~ <br />Phone 970 a~lq - ~~,D3 <br />AC1l1AL WELL IACATION: <br />PROPERTY ADDRESS <br />p-ddn.y (pqq lsr+ul <br />1/4 1/4, Sea Twa ^ N. ^ S., Range ^ E ^ W. _ <br />D~noes from secdort Llnes~l ~"l la. Ft tram ®fJ. ^ s. Unel`13l a31.sFt ham ®E or ~ W. Line. <br />I (we), report that an e~stirg wed was plugged and abandoned for the foeowing reasor-(s): <br />Ttq wee was p4tgged and abandoned as tequtred under the rrondttiorts of <br />approval d Wee Pacmit Na <br />The wet wai rtat h use and rtes a6artdorwd <br />Other (please e~tain) . <br />The wee was gagged and abandoned aooordirtg to the water wee corrstnicdon <br />and Pump 4tstaeadon Rules on ~I 1 A Y~-l ~ q .13 0l DO <br />The wee was pYrggsd w#h the rnatart~ placed at the indicated intervals: <br />AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT ttJTERVAL <br />(~~{ m @. I~ a~ <br />a~ 5 0' <br />~rP irl ~ ~ <br />eQTER1/ALS OF casiNG REMOVED/RIPPm w FEET <br />from feet to feet <br />8orrr~feet to feet <br />from feet to feet <br />from feet to feet <br />from feet to teat <br />from feat to _ _ feet <br />1 (we) have read the staterrrems made herein and larow the mrrerns thereof, and that they are true to my (ourl <br />latowledga (Pusuart m Sectlort 24+104 (1~(a) C.R.S.. the nrakirtg of false statemeras herear oor~atioutas P~AuY <br />in the second degree and fs punishable as a class 1 rtdsdertwanor.) <br />Narrre/ftie (Please tYPa ~ PSI ,~/ a Date <br />t3uy A IQSa,B4 owner .~//~ n. / - ~ L „~~f ~' 3 ~ l ~ 2 <br />oRMAT10lV- 6 is the resporurueity w the w~ oartrer m han+e the wee properly ptugged and abandoned. <br />wee oorrstructiort cormraaor b resporuale for rtot3y~g the wee owner of the pigging and abandoranent re <br />This form rrragl be reproduced by photocopy a word processirg rrraarrs. <br />