2011-12-05_GENERAL DOCUMENTS - C1992081

• Permit No: C1992081
• IBM Index Class Name: GENERAL DOCUMENTS
• Doc Date: 12/5/2011
• Doc Name: Well Abandonment Report
• From: Hayden Gulch Terminal, Inc
• To: DRMS
• Permit Index Doc Type: Exploration
• Email Name: JLE
• Email Name: SB1
• Media Type: D
• Archive: No

Form No.
GWS - 09
10/2011
STATE OF COLORADO, OFFICE
1313 Sherman St. , Ste 821, Denver,
(303) 866 - 3581 Fax [phone]
OF THE STATE ENGINEER
CO 80203
http: / /www.water.state.co.us
For Office Use Only
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 side of form.
Well Permit
MH File
Number of the well being plugged
Number MH- Hole ID
2 ` 1 5 16 — F or
# /Name 1+ G S t o 1 loo We 11 I
Individual /Company responsible for plugging and sealing the well:
NAME(S)
Mailing Address
cit St., zip
Phone (j
Ha j cite -v G..(c k 142.v-tM«I^,q I i M •
t
Pew, lo od E rev q , -f Poe, +� i 0
,
1 atah C 0 639 - 061 t'
� Q- e
70 ) R./ 6- S a 17
Well (Hole) Owner:
__ _ _ . _ _
u Phone ( )
__ ` --
NAME(S)
Mailing Address,
_
Scl -Vv\� c- . S CA_ L 0
City, St., Zip
ACTUAL WELL LOCATION: County Ro■'l-
Property Address,
S W 1/4 of
City, St, Zip -14 C4 4 .8 aE'M , CCU g (
the NE. 1 /4, Sec. 10 , Twp. 6 ['
b P.M.
N. or . S., Range 2 $ • E. or[0
Distance from
Subdivision
Optional: GPS
Format must
Easting
Section Lines 600 Ft. From [
W. Line.
/Unit
( N. or ■ S. 3 a 00 Ft. From ■ E. or L/
Name Lot , Block , Filing
well location information in UTM format. You must check GPS unit for required settings as follows:
be UTM, zone 12 ❑ or zone 13 ❑ ; Units must be meters; Datum must be NAD83; Unit must be set to true north.
Northing
I (we) report
the existing well (hole) was plugged and
was plugged and sealed as required under
was not in use and was plugged and sealed.
explain)
sealed on the date of t 1 1q ti
for the following reason(s):
Well Permit Number
- the well
The well
• Other
(please
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type o Method of Placement
_ G t a c \ Vs " k — • l (3- Ft 3 ()LAN. e c k
from
from
Interval /
0 feet to A b _
Gl.l4. C-0k'1
__feet__
feet to feet
1
from feet to feet
Intervals of casing removed /ripped in feet
from 0 . feet to 5 feet
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
contents thereof, and that they are true to my (our) knowledge.
(we) have read the statements made herein, know the
Signature
Please print the Signer's Name & Title
Date
/ �
X'190/477,04/ ,vfl r/4de_
It is the responsibility 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.