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~'~~-, STATE OF COLORADO ~ For Onko Us. ony ~° OFFICE OF THE STATE ENGWEER rss I me c.nrn+i.t ttiae., rata Shatm~n se.. oenwr. Cdwado cocoa Pt>31 ees.~st OR PRINT W BL/U'.IC WK WELL ABANDONMENT REPORT ABANDONED WEIl NUMBER IF REGISTERt>) ~~ 0~ ~ fl,t n~ I ~ ~ rri ~Q Maffing Address . Q 0~ 8-1! 5~l I 1 cry. sc z~ -~Sm-w~tZ.:rs~~ C:i~ ~ 1~ 3~ Phone 970) U~ 2 A_ CTUAL WELL LOCATION: PROPERTY ADDRESS (~~) ~ 1~t9 f~l 114 1/4, Sea Twp~ ^ N. ^ S.. Range ^ E ^ W. _ O hom Section Lines FL from ^ N. ^ S. Lute, Ft horn ~ E ar ~ W. Lure. I (we), report that an etdstirtg tred was plugged and abandonred for the tdlowing reason(s): The wed was plugged and abardorted as required under the cortd>vorts d approval of Wed Perrot Na The wed was not h use and was abartdawd Other (Please e~taitt) . a. The wed was plugged and abertdorred acoordutg m the Water Wed Cortstructiort and Pimp 4tstaYation Rules on o2 99~I~(O ~ i The wed was pkrgged with the materials placed at the 6'tdicated Intervals: AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL ~ ~ ~_ ~L Try, m i ~P Vom~2fees to 5 ~ feet t~ a7 50' ~ tram feerm feet rrom feet to feet INTERVALS OF CASWG REMOVED/RIPPED dV FEET from feet to feet from feet to . , _ - tees I (we) have read the sreterrrertts made herein and Imow the contents thereof, and that they are true to my (our) IuloriAedge. [Pursuant to Section 24~-104 (1~(a) C.RS., the makirg of false stazemerns herein perjury in the record degree and La purtlsftable as a class 1 misderrreanor.] Name/title (Please type cr print) S•ig-atsre Date ~Ya ~ -~., ion. ,/~.~~, ~.,~ ~1~~1 ~ T10M- n Is the resporm,>St„ of the wen owner m have the wed peopesly pkgged and abandoned. wed oortstructiort oortrraetcr Is resportsate fa rtooay:tg the wet owner a the ptggirtg and 8bartd0(Yitent re This form may be reproduced by P~ocoPY or word procassftg means.