2009-09-17_GENERAL DOCUMENTS - C1980001 ‎(2)‎

• Permit No: C1980001
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 9/17/2009
• Doc Name: Well Abandonment Reports
• From: WWC Engineering
• To: Office of State Engineer
• Permit Index Doc Type: Exploration
• Email Name: JDM
• Media Type: D
• Archive: No

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 [phone] Fax [phone] 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 TR-1.5
Individual/Comoany responsible for plugging and sealing the well:
NAME(S) WWC Engineering
Mailing Address 611 Skyline Road
City, St., Zip Laramie. WY 82070
Phone [phone]
Well (Hole) Owner:
NAME(S) Maplewood Financial Inc.: William Dulan Phone [phone]
Mailing Address, City, St., Zip 3001 S Lincoln Avenue Steamboat Springs, CO 80487
ACTUAL WELL LOCATION: County Routt
Property Address, City, St, Zip Pt Of Tract 41 In SE1/4 & Pt Of Tract 40 In NE114 SEC 14-4-86 Total: 52.9 Acres
NW 1/4 of the SE 1/4, Sec. 14, Twp. 4 N. Range 86 W., 6 P.M.
Distance from Section Lines 2041.74 Ft. From S. Line, 1718.26 Ft. From E. 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
Easting 329693.06 Northing 4464950.85 Elevation 2192
I (we) report the existing well (hole) was plugged and sealed on the date of 09/08/09 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" PVC 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, 100 Pounds Funnel Downhole from 4 ft-bgs to 14 ft-bgs
Intervals of Casing Removed Ripped in Feet from 2 ft-ags to 4 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
IeVVV Troy Summers, Associate Geologist September 15, 2009
It-is the res ' ' y 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.