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Form No. <br />GWS -09 <br />5/2011 <br />STATE OF COLORADO, OFFICE <br />821 Centennial Bldg., 1313 Sherman <br />(303) 866 -3581 Fax (303) 866 -3589 <br />OF THE STATE <br />St., Denver, CO 80203 <br />hftp://www.water.state.co.us <br />1 For Office Use Only <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 si8e of form. <br />Well Permit <br />MH File <br />Number of the well being plugged <br />Number MH- Hole ID <br />or <br />*Name <br />Individual /Company responsible for plugging and sealing the well: <br />NAME(S) <br />Mailing Address <br />City, St, Zip <br />Phone ( <br />) <br />Well (Hole) Owner: <br />Phone ( ) <br />NAME(S) <br />Mailing Address, <br />City, St, Zip <br />ACTUAL WELL LOCATION: County <br />Property Address, <br />1l4 <br />City, St, Zip <br />P.M. <br />of the 1/4, Sec. . Twp. <br />• N. or N S., Range • E or • W., <br />Distance from <br />Subdivision <br />Optional: <br />Format must <br />Easting <br />Section Lines Ft From ■ N. or i S. Ft From u E. or . <br />W. Line. <br />Name Lot . Block Filing/Unit <br />GPS well location information in UTM format. You must check GPS unit for required settings <br />as follows: <br />Unit must be set to true north. <br />be UTM, zone 12 • or zone 13 • ; Units must be meters; Datum must be NAD83; <br />Northing <br />I (we) report <br />0 The well <br />the existing well (hole) was plugged and <br />was plugged and sealed as required under <br />was not in use and was plugged and sealed. <br />explain) <br />sealed on the date of <br />for the following reason(s): <br />Well Permit Number . <br />• The well <br />• Other (please <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 />from feet to feet <br />from feet to feet <br />from feet to feet <br />Intervals of casing removed /ripped in feet <br />from feet to feet <br />Report must be signed by person who performed the <br />well plugging work or by the well owner if this person is unknown or not reachable. I <br />contents thereof, and that they are true to my (our) knowledge. <br />(we) have read the statements made herein, knowthe <br />Signature(s) <br />Please print the Signer's Name & Title <br />Date <br />It is the responsibility of the well owner to have the wellhole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of this requirement. <br />-ridmt Ge-,vzue <br />2, 3 <br />