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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 40o or <br />MH File Number MH- Hole ID #/Name <br />Individual/Company responsible for plugging and sealing the well: <br />NAME(S) C6RS; Tile. <br />Mailing Address P. o• Gox 1 9 <br />City, St., Zip Forf 60111'AG 6,0 RD564 <br />Phone ( ) yV- 330b <br />Well (Hole) Owner: <br />NAME(S) CCzM E k Phone (30) $ 3 - a 140 <br />Mailing Address, City, St., Zip 13 Vie. koad Lon f G $050 <br />ACTUAL WELL LOCATION: County &WIde-r <br />Property Address, City, St, Zip 1?q U!k- Poaid L ov?Annov%`l + (gip $0503 <br />`' 1/4 of the 1/4, Sec. o1&Twp. _?_ vl. or [:]S., Range _4 E]E. oreW., S P.M. <br />Distance from Section Lines 3dob Ft. From ? N. or g! ,., 18"T5 Ft. From ? E. or [eW. Line. <br />Subdivision Name Lot , Block , 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 U TM, zone 12 ? or zone 13 M Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />Easting ?? / 1 .3/01.Northing 04q /749-S <br />I (we) report the existing well (hole) was plugged and sealed on the date of ?iv - S - a 0 /0 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) 11,;..; we.ll P?nll ao5? under na`Fura j Caid,`l;'erG -!T a- 14" h off' v 3-74ef d Blois <br />- <br />' 1 OA was H I 1ALdidovieJ role- <br />d <br />1?-'The well was plugged wi h the followin materials placed at the indicated intervals: Ilo r•3° <br />Amount and Type of Material Method of Placement Interval <br />.6en-6ni4,e- I hvdrafeJ Byerl 7°5 f+? i4rLLVj'4Aj from. 34 feetto 5.5' feet <br />from S.5 feetto ©.5 feet <br />NA.'Ne. 5r,rj; c l ar. j So 15 from D • 5 feet to D. D feet <br />Intervals of casing removed/ripped in feet from 6.5 feet to A 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 />Signature(s) 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.