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~~' STATE OF COLORADO Fa Otse~ w ody <br />ewe OFFICE OF THE STATE ENGWEEFi <br />rtes <br />618 CaurmW emp., tats SMnn.n SL, o.uw.. t:obrado 902Da - -- <br />Prol eesa~et <br />OR PRkJT W BLACK WK <br />WELL ABANDONMENT REPORT <br />NUMBER ~ <br />z <br />WDMDU MPANY PONSIBLE <br />mown_ m C ~ C ~ p LL <br />NAMES] , JU z' S E 1 K i rC.~ <br />Maaug Address , P O~~ 5 G 1 <br />Phase vio qaq- ~3d'~ <br />2 ACTUAL WELL LOCA710N: <br />PROPERTY ADDRESS ' <br />1~~4 t~ l~M <br />t/4 f/4, Sec. Twp. ^ N. ^ S., Range ^ E ^ W. _ <br />Dis>artces from Section Lines 3 .(AFL tram ~ N. ^ 3. Wte,1~ 3"15X1 •~FL from ~ E o~ ^ W. Line. <br />I (we), report tltat an e~tktg well was plugged and abandoned for the fo0owing reason(s): <br />^ The we0 was pktgged and abandoned as regtdred under me oortdulona a <br />aPPro+ral al Weq Permit No. <br />The weC was not in use and was abarrdatad <br />Other (please ) . <br />s. The weo was pigged and abendorted accort5ng to the water We9 Corwtrucoion <br />and Pump klstaGarlart Rules on 14~~20 .I <br />x The wail was pigcled with trio toGawirg maeertals placed ffi the k,~aced Iruervalr <br />AMOUNT AND TYPE OF MATERWL METHOD OF PLACEMENT WTERVAL <br />~ 61 AL ir-r° m i e, <br />t` Of <br />WTERVALS OF CASINO REMOVED/R~PED W FEET <br />Tram leer to feet <br />from~feet to SQfeet <br />from feet >n feet <br />from feet to feet <br />from feet to feet <br />Trout teat to , . _fed <br />i. t (we) have read the sratenteras made herein and know the coruertu tftereof, and that they are true to my (air) <br />Ivtowledge. [Pursuant to Section ?A~-104 (f3~(a) C.R.S.. the making of false staternertts herein coc~ums f~tlmY <br />in the second degree and Is punishable as a doss f misdemeanor.] <br />Narre/rale type a Print) I ~ ~~ ~-c~ / ' J/~~ / ~~. I <br />icy Q Owner <br />TION- k is Ute resporm'bTly of the we0 owner to have the we9 properly pugged and abandoned. <br />weA Corsuucdon oormactor is respormble for natifyig the we9 owner d the pigging and abandorvner>< re <br />Ttt6 form may lie reproduced by pttotooopy or word ptotwssktg trtearts. <br />