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2~Fb5o F pa9~, 7 <br /> FOAM N,O, <br />exss y~A~ OF COLORADO Far Oiflee Ues only <br /> <br />r~ OFFICE OF THE STATE ENGINEER <br /> 818 Cerdartnief 9ldg., 1313 Sherman St, Oerrvar, Colorado BrYL03 <br /> (303) [t86.3R8t <br /> E OR PRINT IN BLACK INK <br /> WELL ABANDONMENT RE~O~ <br />r <br /> ABANDONED WELL NUMBER IF REGISTERm ~ <br /> 1. INDMDUAUCOMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) r <br /> Mailing Address <br /> city, St. ZP 6 <br /> Phone (ct~0) - <br /> 2 _ACTUAL WELL LOCATION: •COUNTY b <br /> PROPEFt1Y ADDRESS <br /> (Addrus! tC1b) (State) (IIt~ <br /> _~_1/4 E 1/4, Sec.~~, Twp. ~ _ ®N. ^ S., Range, ^ E <br />~ <br />W. ~P.M <br /> r <br />~ <br />Distances from Section Lines ~ <br />Ft from ®N <br />~~ FC from LG-E or ~ W <br />Line <br />Line <br />^ S <br /> _ <br />. <br />. <br />. <br />, <br />. <br /> 3. 1 (we), report that an erdstirtg well was plugged and abandoned for the folowing reason(s): <br /> The well was plugged and abandoned a; required under the conditlons of <br /> approval of Well Permit No. ____QzY~. <br /> The wet{ was not in use and was abandoned <br /> Otfier (please explain) <br /> <br /> 4. The well was plugged and abandoned according to the Water Well Construction <br /> and Pump InstallaflOrt Rotes an Q3J%~. . 19 <br /> 5, The weU was plugged with the following materials placed at the indicated irtterva4s: <br /> AMO AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL <br /> 3!! lr~ ~l~ ~ t n ~'-+ r'a:~ ~a~ C~0 1 r o Q~ trom~et to ,~~eet <br /> ~y' ~ G7L(,ALL(~et to ~eet <br />~ <br /> _~ r. ~D ~ fro <br />m`_~feet to ~D~#eet <br /> .s , ~ hrJOltS~`2 t~ from d feet to Meet <br /> INTERVALS OF CASING REMOVED/RIPPED IN FEET from feet to feet <br /> from feet to feet <br /> 6. I (wej have read the statemerrts made herein and know the contents thereof, and that they are true m my (our) <br /> knowledge. [Pursuant to Ser.Kicn.24-4-104 (13)(a) C.RS., the making of false statemerrts herein cronstitutes perjury <br /> in the second degree and is punishable as a class 1 misdemeanor.] <br /> e/T'rve (Please type or print) <br />~ ig atur Date <br /> ' RC»2 ~ <br /> ~• ~REGo.2 / r' ,' <br /> ORMATION- It is the resportsibi dy of the well owner to have the well property plugged antl abandoned. <br /> The well construction conaactar is resportsihle for notifying the we{I owner of the plugging and abandonment requirement <br /> This farm may be reproduced by photocopy or word processing means. <br />