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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 or <br />MH File Number MH- Hole ID ##/Name N\ - In <br />Individual/Company responsible for oluaaing and sealing the well: <br />NAME(S) \ cry\r\?, c????>e?5c? <br />Mailing Address <br />City, St., Zip ?\l`? Q?C?. C Q SOU\\ <br />Phone <br />Well (Hole) Owner: <br />NAME(S) Phone <br /> <br />?'????\`???\`L`V \V`C '??C >Z , LQ\11\0 <br />Mailing Address, City, St., Zip <br />ACTUAL WELL LOCATION: County <br />Property Address, City, St, Zip "S\<?\???,C?y <br /> <br />1/4, Sec. b , Twp. ? N. or® S., Range ?O E] E. ortZ] W., P.M. <br />1/4 of the )L-\ <br />Distance from Section Lines Ft. From M N. or ? S., \ , I-IC313 Ft. From [] E. or ? W. Line. <br />Subdivision Name N\-A Lot ti1\ Block n\A , Filing/Unit kN'R <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows: <br />Format must be UTM, zone 1213 or zone 13 0 ; Units must be meters; Datum must be NAD83; Unit must beset to true north. <br />Easting Northing --...,......._....-,....__ ...__ _ <br />I (we) report the existing well (hole) was plugged and sealed on the date of for the following reason(s): <br />? The well was plugged and sealed as required under Well Permit Number <br />50 The well was not in use and was plugged and sealed. <br />0 Other (please explain) <br />- <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 />?52ea? CQ,\r? ??? <?Q (}\\?if?? '\?f2?\?\ Q`??`Z from feet to J? feet <br /> <br />from feet to feet <br />from feet to feet <br />Intervals of casing removed/ripped in feet from feet to feet <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. I <br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Signa utr(s) Please print the Signer's Name & Title Date <br /> <br /> <br /> 4'?1 ; to <br />It is the responsibility of the well owner to have the well/hole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement.