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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-J\°\\O Hole ID #/Name \`I\NJ c`3 <br />Individual/Company responsible for pluoaing and sealing the well: <br />NAME(S) V"VNR- C\?c\s\c-rS <br />Mailing Address <br />City, St., Zip ?`\?`f CX C\ , C gy?j\\ <br />Phone <br />Well (Hole) Owner: <br />NAME(S) Phone (-\\"N <br />Mailing Address, City, St., Zip \\\??W??I VU, \ \OC \?? ? \?,`Z\p <br />ACTUAL WELL LOCATION: County <br />Property Address, City, St, Zip <br />N'E 1/4 of theSk 1/4, Sec. -1-, Twp. ? N. or U S., Range ? E. orM W., tr' P.M. <br />Distance from Section Lines ?-s1- Ft. From ? N. or (U S., Ft. From M E. or ? W. Line. <br />Subdivision Name 111 Lot ?\1\N , Block Vl?? , Filing/Unit <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 12 O or zone 13 ? ; Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />Northing <br />Easting <br />_ <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 />The well was not in use and was plugged and sealed. <br />Other (please explain) <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 />" <br />G, V 1 <br />O <br />O cu\\ <br />' <br />' <br />« <br />CaRS <br />? <br />ZC <br />feetto <br />4\ Ce?,\?11\ C CO\kr Q feet <br />from <br />- <br />awl coq o G o?\ \".?\U ?- <br />X)e\w\C? V< ?\?\ \ b0N?0 Vco\' w1 -\ CU-\'?A frorrRW I?' feet toy -)Q 2 ? feet <br />S\?\CCA ?,C?t? ??\\t,?`t?C?> `^? boci??) ??t?2Q?C\?\ V '\t\ O,S\?q from%Q Q5„feet to \\?1 feet <br />Intervals of casing removed/ripped in feet from _ feet to feet <br />_____.. <br />_ <br />.._.. <br />. <br />._ <br />. <br />. <br />_........_._._.._._.....__._..._.__...._......... ....... ............... ._.__...._.___ <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 />Signature) Please print the Signer's Name & Title Date <br /> <br /> <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.