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. i c QF CCLGFADC Fror ,^7flce Use anN <br />~FiCc OF THE S~Aic E:VCWE=~ <br />d16 Cantennid 91aq.. iJ13 Shsrtnen 8L. Camsr. Glando BC.CC <br />(,'.C.") 866 t~a7 <br />' .4rJT IN BLACX INK OL~ <br />ELL ABANDONMENT RE~0~3~ A <br />~NE] WE~ NUMBEa IF RE~iSc?.E7~//n ~•- f- ~ TC R ~~' L <br />MCU? ;;C~MF4NY =E~~CNSiEL= FCF.%LUG/'GiNC <br />'S} IJ r 0 i ~ I (1 C' ~ ~ ~ ~1 i r1 ~ l (~ ~ ~ nG . <br />ling ACCress <br />Zo n C <br />~~L.~10~.-~l - r11 <br />i L WE1 LOCATION: -COUNTY [7 Lo r~,~~ <br />E9T'/ ACGRE3S ~ T <br />(Addrea (uY) (sraee! (rP) <br />Cif/4 ~E 1/4, Sec~_ Twp.~_ ®N. ^ S., Range ~ E. ~~{ W. _~P.M. <br />antes rrom Serion Lines 3/ay _Pt from ®N. ^ S. Lane, _ ~J/ (~ FL from LrJ-c or 0 W. Line. <br />repcrt that an existing well was plugged and abandcned far the fellcwing reascn(s): <br />e well was plugged anC abandoned a5 required under the ccnCiticrs of <br />croval of Well Permit No. 9 J(/~ /iS~. <br />~e well was nci in use and was abandoneC. <br />~er (please explain) <br />II was plugged and abandCned accarCing to the Water Well CCnsduc~Cn <br />'~mp Ins:allaticn Rules on G2~L/C~ , 19~. <br />well was plugged with the fcilcwing maferfals placed a< the indicted irttervals: <br />,C~~ AND TYP° OF frtAc cr+lAL METi-ICD OF PLACc4tEiYf INTEVAL <br />~ (r~ ~, .~ ~ n -, rCi ~r~~ 0 t_ ~ from ~ to ~Q'eet <br />n 6 L.Lp1,t~~ieet to ~eet <br />7 <br />~Pr~ ~ ~,-~.~ rig 1. ~i~ r. ~D from~Ofeetro~0~eet <br />/~ r~- <br />I ' ~ La-i ~ n ~ I _ Ic~G~ C~' ircm C) feet ro /~_fe=t <br />ALS GF CASING RE'4tOVE7/RlPPE~ IN F~ ii <br />from feet ro feet <br />from feet to Seer <br />read die statements made herein and knew d:e contents tl^erecf, and that they are tn:e ro my (cur) <br />[Fursuart to Secdcn 2aY104 (13}(a) C.9.S., the making of fdse statements herein rnsdh.2es perjury <br />d Cegree and is punishable as a crass t misCameancr.] <br />i ale (P!e~a type cr print) <br />1~ 2 <br />'~EC-v2r' l~iz-Er <br />CN- It is the n=sccnsitif"dy cf the we!I cwrer to hove tl^e well prcperiy plugged and abandcreC. <br />~isaucicn ccrmaccr is respcnsrtte fcr ncrifying dte weft cwner of the plugging anC atandonmerrc re <br />t may to reproduced ty photocopy or wcnl procassng means <br />