Laserfiche WebLink
GW -9 -76 <br />DIVISION OF WATER RESOURCES <br />1313 s15ERMAN STREET RM. 818 <br />DENVER, C0L0RADO 80203 <br />WELL ABANDONMENT AFFIDAVIT* <br />STATE OF COLORADO ) <br />ss. <br />COUNTY OF Rio Blanco ) <br />1 (we) W. C. Day for Superior Oil Com. <br />first duly sworn upon oath, despose and say: <br />That an old well, located in the NE 1/4 of the NW 1/4, Section <br />Township 1 Range 97 W . 6th P.M., was replaced <br />for the following reason(s): <br />Well was filled back in due to TDS being too high. It was <br />not replaced. <br />That the old well, which was replaced by a new well drilled under permit <br />number well was not replac as plugged and abandoned according to the <br />rules and regulations of the State Board of Examiners of Water Well and Pump <br />Installation Contractors by W. C. Day Water Pump Supply and Service <br />(person (s) or company) <br />on , 19. <br />That the old well was plugged with the following materials placed at the <br />indicated intervals: gravel from 50 ft to 15 ft then cement to 5' then filled <br />with dirt to surface <br />gravel f rom 50 feet to 15 fee: <br />cement 15 5 <br />dirr i ,, from 5 feet to , 0 feet <br />Signature of aff cant (s) lit ) e <br />Subscribed and sworn to before me this <br />of Jot n urtr � <br />, <br />My Commission expires: 47/5T / R A' <br />Notary Pub <br />P_A ru t r 7q- <br />RECEIVED <br />JAN 2 5 1988 <br />,being <br />1 <br />day <br />*It is the owner's responsibility pursuant to the conditions of approval to see <br />that the affidavit is returned. <br />(See reverse side for Abandonment Regulations) <br />