2008-08-08_GENERAL DOCUMENTS - C1980001

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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only GWS-09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 6/2006 (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us WELL ABANDONMENT REPORT Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or print in black or blue ink. Instructions and plugging standards are on reverse side of form. Well Permit Number of the well being plugged Monitoring Well Not Permitted or MH File Number MH- Hole ID #/Name 05-01-0005 Individual/Company responsible for plugging and sealing the well: NAME(S) WWC Engineering Mailing Address 611 Skyline Road City, St., Zip Laramie, WY 82070 Phone (307) 742-0031 Well (Hole) Owner: NAME(S) United States of America, Bureau of Land Management Phone (970) 826-5077 Mailing Address, City, St., Zip BLM 455 Emerson Street, Craig, Colorado 81625-1129 ACTUAL WELL LOCATION: County Routt Property Address, City, St, Zip 6 Miles Northwest of Oak Creek. Colorado NE 1/4 of the NW 1/4, Sec. 30, Twp. 5 N. Range 85 W., 6 P.M. Distance from Section Lines 1267.30 Ft. From N. Line, 2216.98 Ft. From W. Line. Subdivision Name N/A, Lot N/A, Block N/A, Filing/Unit N/A Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: UTM zone 13 Units Meters Datum NAD83 Eastin 332959.94 Northing 4470198.01 Elevation 2290 I (we) report the existing well (hole) was plugged and sealed on the date of 07/24/08 for the following reason(s): The well was plugged and sealed as required under Well Permit Number N/A. X The well was not in use and was plugged and sealed. X Other (please explain) 4" Metal Monitoring Well was removed from Groundwater Monitoring Program of PN C-80-001. The well was plugged with the following materials placed at the indicated intervals: Amount and Type of Material Method of Placement Interval Black Hills Bentonite: Bentonite Plug, 387.5 Pounds Funnel Downhole from 5 ft-bqs to 48.5 ft-bgs Intervals of Casing Removed Ripped in Feet from 0.5 ft-ags to 5 ft-bgs 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. I we have read the statements made herein, know the contents thereof, and that the are true tom our knowledge. Signature(s) Please print the Signer's Name & Title Date Troy Summers, Associate Geologist August 6, 2008 It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor is responsible for notifying the owner of this requirement.