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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br />GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />6/2006 (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or <br />print in black or blue ink. Instructions and plugging standards are on reverse side of form. <br />Well Permit Number of the well being plugged Monitoring Well Not Permitted <br />or MH File Number MH- Hole ID #/Name OK1 <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) WWC Engineering <br />Mailing Address 611 Skyline Road <br />City, St., Zip Laramie. WY 82070 <br />Phone (307) 742-0031 <br />Well (Hole) Owner: <br />NAME(S) Maplewood Financial Inc.; William Dulan Phone (970) 879-8101 <br />Mailing Address, City, St., Zip 3001 S. Lincoln Avenue, Steamboat Springs, CO 80487 <br />ACTUAL WELL LOCATION: County Routt <br />Property Address, City, St, Zip 2 Miles North of Oak Creek. Colorado <br />SE 1/4 of the SE 1/4, Sec. 19, Twp. 4 N. Range 85 W., 6 P.M. <br />Distance from Section Lines 887.02 Ft. From S. Line, 483.02 Ft. From E. Line. <br />Subdivision Name N/A, Lot N/A, Block N/A, Filing/Unit N/A <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br />UTM zone 13 Units Meters Datum NAD83 <br />Eastin 333256.55 Northing 4463013.12 Elevation 2163 <br />1 (we) report the existing well (hole) was plugged and sealed on the date of 06/10/08 for the following reason(s): <br />The well was plugged and sealed as required under Well Permit Number N/A. <br />X The well was not in use and was plugged and sealed. <br />X Other (please explain) 4° PVC Monitoring Well was removed from Groundwater Monitoring Program of PN C-80-001. <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Method of Placement Interval <br />Black Hills Bentonite; Bentonite Plug, 100 Pounds Funnel Downhole from 2.5 ft-bgs to 14.8 ft-bps <br />Intervals of Casing Removed Ripped in Feet from 0 ft-aqs to 2.5 ft-bgs <br />Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. <br />I we have read the statements made herein, know the contents thereof, and that the are true tom our knowledge. <br />Signature s Please print the Signer's Name & Title Date <br /> Troy Summers, Associate Geologist August 6, 2008 <br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction <br />Contractor is responsible for notifying the owner of this requirement.