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wRwnto.~ STATE OF COLORADO For aeb. u.. ody <br />°~° OFFlCE OF THE STATE ENGWEER <br />rtes <br />ate CwnmrNfd eldp., tats Slwm~n st, DaMr, Cobraao e620.i <br />l~ tw6aset <br />~,fPE OR PReQT W BL/U'.K fNK <br />WELL ABANDONMENT REPORT r= <br />As/wDONED WELL NUMBER ~ REGi~^TEf1ED Nole ~Q C~ <br />INDMDU OMPANY RESPONS LE FOR P <br />~~. VvEST1 ~ LK PVI ON1t~~~ IrLL <br />M~9 PO O~c 5~i I <br />Cty, SL ~p S o rv~.r 5 ~ ~ ~ 'S5 l ~l 3~ <br />Pitons 970 9 ~. G - ;l ~ 0 3 <br />ACTUAL WELL LOCATION: CO <br />PROPERTY ADDRESS ~J I-1 <br />V~~ ~ (cM l~l <br />t/4 t/4, Sec. TWp. ^ N. ^ S.. Range ^ E ^ W. , <br />Di~ances from Section Linos Ft from ~ N. ^ S. Liner 315q • ~1FL han ~ E ar ^ W. Ltrie. <br />I (we), report tltat an eadsting wee was phrpged and abandoned for the folbwirg reason(s): <br />^ The wee was p4tgged and abandoned es required under the condeions of <br />apprrxal of Web Permt No. <br />The wee was not h use and was abandored. <br />0. The wee was p4rgged and according to the Water Wee Corauuction <br />and Pump 4rsteoa0on Rules on ~,~,. <br />i The wee was plugged witlt fJre mateAa~ placed at the frdk~ted intervals <br />AMOUNT AND TYPE OF MATERIAL METHOD OF PLACEMENT URIIiVAL <br />1~ c~ ('~ rrt.e, ~ 5 C~ L I re m', -e <br />l 50' <br />INTERVALS OF CASWG REMOVED/RIPPED W FEET <br />from feet to feet <br />from ( teat to ~ D teat <br />from feet to feet <br />from teat to feet <br />from feet to fe6t <br />from feet to ... _feet <br />1 (we) have read the statemetus made herein and lutow the coruents thereof. and tftat they are true to my (our) <br />ImoN4edge, jPun~ to Section 244104 (iS)(a) C.RS., the making of faL4e stateriterus herein perjury <br />in the record degree and is ptatishable as a class 1 rtdsdemeartor.] <br />Name/iitle (Please type ar priru) <br />~a~~ <br />~~~ 1~13,1~~ <br />TtON- h is the respormDl3y of the wee owner to have the wee properly pkrgged and abandoned <br />well oorrstnutiart ocraractor b resparrs~le fa rwtdyfrg the wee owner of ttre ptuggirrg and attandoMteru re <br />This form may be reproduced by photocopy a word prooessig means. <br />