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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 XName <br />Individual/Company responsible for pluagina and sealing the well: <br />NAME(S) ?-?`y C-\\S?S <br />Mailing Address <br />City, St., Zip ?b`?`C??. , C $?\\ <br />Phone ("I? 0 <br />Well (Hole) Owner: <br />NAME(S) \,£J\C.\"\ Phone ( 1\°\ ) 1rt'??i "\?Z? <br />Mailing Address, City, St., Zip ?aG?CS3 ??``?1?`-?? \?-? t \Ot?2?l\CL l?\rL'?\O <br />ACTUAL WELL LOCATION: County VTQ-VL\Q " <br />Property Address, City, St, Zip '?SCSJ \X\a`t??iC?V \2? ? <br />'"1/4 of the S?1/4, Sec. \p , Twp. 2aO N. o'Q j S., Range ?o ? E. orM W., 0\\ P.M. <br />Distance from Section Lines\ i ? Ft. From ? N. or N S., Ft. From ? E. or (2g W. Line. <br />Subdivision Name t*?:Ik\ Lot Block *t A , Filing/Unit NA _ <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 11 or zone 13 0 ; Units must be meters; Datum must be NAD83; Unit must beset to true north. <br />Easting <br />Northing <br />_ <br />tt <br />I (we) report the existing well (hole) was plugged and sealed on the date of ??t0 Oq for the following reason(s): <br />? The well was plugged and sealed as required under Well Permit Number <br />MThe well was not in use and was plugged and sealed. <br />E-1 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 />rQtS?? CQ?i g?OVi ?O c?c\\\??5? \ ftZ ???? ?`?Qtt from 4 feet to `\?-- feet <br />Iw 5`v <br />bra) ?C?\\? ` ?? C L1S`M? from feet to feet <br />b??.?\c?t1?\? C\t???.5 C \ <br />+ <br />from feet to 5 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 />Signatures Please print the Signer's Name & Title Date <br /> <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.