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Fa\IND.~ STATE OF COLORADO Far Otno~ Uw oNy <br />~~ OFFICE OF THE STATE ENODdEER <br />ate camr.ir Bldg.. 13t9 snrm.a St, D.~Mr, Colowao eaaD3 <br />pawl enaasst <br />OR PReYT W Bl/1CtC emc <br />WELL ABANDONMENT REPORT <br />ABANDONED WE7_L NUMBER ~ REGISTERED I{012 = 0 . ~~ U ~ ~ <br />-110 ~ 0.,i n Ct;~ Co7~` Pte' <br />Mal&tg 07( 5q I <br />~Y. St. Zip So~rne..Y-5:e ~ ~~:¢_____~1~-13 <br />Prtate quo q ~ ~ - d.. n~1.. ~? <br />z l AcTUA~ wElt i!0(.ATM <br />PROPt3iTY ADDRESS <br />1/4 1/a, sec. Twp. ~ N. ~ S. Range ^ E ^ W. . <br />fMtartces kom setxiort ones NIA Fc tnxn 0 N. ^ a one. Ft. Iran ~ E o.0 w. one. <br />1 (we), repot drat an e~dstitg wee was plugged and abarworted for the toeowing reason(s): <br />The trees was p4rgged and ahartdorred as requ4ed under ttte cortdhlorts of <br />approval at Wee Pemta No. <br />The wee was not fn use and was abartdorwd <br />I outer (Please ~) . <br />Ttta wee was plugged and abandoned acoadutg to the water wee Cortstructiat <br />and Pump kwtauatiort Rules on Q ~ 1.~ ~a 1 1g~1Q0 1 <br />The wee was plugged w+lfr the tg rrl~terlats placed at the fndir~ed iruervals: <br />AMOUNT AND TYPE OF MATERUIL METHOD OF PI.ACEAIEAIT W'TER1/AL <br />Q, tY~, /-~0 A i e. <br />~ Ol <br />eYTEFt1/ALS OF CASINO HEMOVED/R~PE'D M FEET <br />from feet to feet <br />from teat to feet <br />from teat to feet <br />from feet [o feet <br />from feet to feet <br />from lest to . -feet <br />1 (tve) Nave read the statements made herein and letow the oorttertts thereof. and drat they are true to my (out) <br />tvrawAedge. (PurtwarY to Section 2~w-toe (13J(a) c.R.s.. me malting ar false staterrrerus herein Paiary <br />in the second degree and fs punishable as a lass t rr~etneanor.] <br />Name/ftle (Please type ar prim Stgrtauae Data I <br />ar,Y a IQssrtet: oNrter ;~%~ ~ ~i-~ n.~i ~I311d a <br />TION-- R is the resporm~Sty oI dte wee amer to have dte weU properly p4rgged ana abarWOned <br />The well oatsvuctiart contractor is resportsr~le Tor notifytrtg the wee owner d the pwrggirtg and abartdCrnrtertt re <br />Tiffs lam may be reproduced by photocopy a word proosssing mear>s. <br />