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<br />FORMNO. STATE OF COLORADO For Office Use only <br />7/89 <br />7/89 OFFICE OF THE STATE ENGINEER <br /> 818 Centennial Bldg., 1313 Sherman St, Denver, Colorado 80203 <br /> (303) 866-3581 <br />E OR PRINT IN BLACK INK <br />WELL ABANDONMENT REF <br />ABANDONED WELL NUMBER IF REGISTERED <br />1. INDMDUAUCOMPANY RESPONSIBLE FOR PLUGGING <br /> NAME(S) r C? <br /> Mailing Address <br /> City, St. Zip Yolol <br /> Phone (9-1o ) <br />2. ACTUAL WELL LOCATION: -COUNTY 6 <br /> PROPERTY ADDRESS <br /> (/Address) (City) (State) (4p) <br /> _1/4 _S6-1/4, sea_ 2s-- Twp. IdJ N. 11 S., Range_ ° y E. 21 W. P.M. <br /> Distances from Section Lines 3186 Ft. from EO N. ? S. Line, '7/ C1 FL from [Z-E. or 0 W. Line. <br />3. 1 (we), report that an existing well was plugged and abandoned for the following reason(s): <br /> WThe well was plugged and abandoned a$ required under the conditions of <br /> approval of Well Permit No. 7 1/72• <br /> The well was not in use and was abandoned. <br /> Other (please explain) <br /> <br />4. The well was plugged and abandoned according to the Water Well Construction <br /> and Pump Installation Rules on OLIO , 19__?L. <br />S. The well was plugged with the following materials placed at the indicated intervals: <br /> AMQX? NT AND TYPE OF MATERIAL METHOD OF PLACEMENT INTERVAL <br /> <br />CLr C? (I from 0 ?eet to E?(?eet <br />??l 0 <br /> OR nil r0-r,_L Q GD.Lt ALL(??t to ?eet <br />? <br /> ' <br />from ?_LO feet to <br />) 04eet <br /> _,: <br /> JO L&^ f - from 6 feet to /n feet <br /> INTERVALS OF CASING REMOVED/RIPPED IN FEET from feet to feet <br /> from feet to feet <br />6. 1 (we) have read the statements made herein and know the contents thereof, and that they are true to my (our) <br /> knowledge. [Pursuant to Section 244104 (13) (a) C.R.S., the making of false statements herein constitutes perjury <br /> in the second degree and is punishable as a class 1 misdemeanor.) <br />N/?me/T Title (Please type or print) ig <br />1 Date <br /> <br />(.'v?t)? • C T-0 It r7 <br />C°A2EGvk a/ <br />E, el 4 <br />_ <br />-INFORMATION- It is the respcnsibi dy of the well owner to have the well property plugged and abandoned. <br />The well construction contractor is responsible for notifying the well owner of the plugging and abandonment requirement <br />This form may be reproduced by photocopy or word processing means.