Laserfiche WebLink
Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />GWS 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />4/2012 (303) 866 -3581 Fax ( 303) 866 -3589 dwroermidsordineti6ftsta te.co.ii, <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other toles. This Porn can be <br />computer generated, typed or pruned in blade or blue Ink Instructions and pugging standards are on <br />reverse side of form. <br />Well Permit Number of the well being plugged or <br />MH File Number MH Hob ID Mame 812 <br />Jndividual/Comoanv responsible for oiuogina and sealing the well: <br />Names) GODBE DRILLING LLC. <br />Mailing Address 62802 OHLM ROAD <br />City, st, Zip MONTROSE, CO, 81403 <br />Phone (area code 8 no.) 970 -240 -6108 &at: jjgodbeaa0 <br />Well (Hole) Owner: <br />NAME(S) GOLD HILL MINERALS <br />Mailing Address, City, St, Zip PO BOX 191127, MIAMI BEACH, FL, 33119 -1127 <br />For Office Use Only <br />Phone (inckxle area code) 305 <br />ACTUAL WELL LOCATION County BOULDER {{ t !� sr <br />Property Address, City, St Zip ale 6 1 - k P./ et 10.4.4 P AA • , J cum v ‘xss <br />hie 1/4 of the5a1 /4, Sec. 2 1, Nip. ?- ®,N. or D S., Range 7.2 0 E. or E3' W., P.M. G`al <br />Distance from Section Lines 23 Ft. from jit N. or C S., ,/O?P Ft from E. or ® W Line. <br />Subdivision Name Lot , Block , FiingFUnit <br />Optional: GPS weN location information in UTM format You must check GPS unit for required settings as follows: <br />Format must be UTM, zone 12 0 or zone '13 Units must be meters; Datum must be NAD83; Unit must be set to true north, <br />Easting 45 2 Northing 4 4 <br />1 (we) report the existing well (hole) was plugged and sealed on the date of 143 <br />D The wolf was plugged and sealed as required under Well Permit Number <br />D The well was not in use and was plugged and seared. <br />Other (please em lain) CORE DRILL BORE HOLE ( ALL CASINGS REMOVED) <br />If signing print name & title <br />11 <br />for the following roason(s). <br />BRIAN MANTEI GOOSE DRILL FOREMAN 10/1312012 <br />The well was plugged with the following materials placed at the indicated intervals. <br />Amount and Type of Material Method of Placement I nterva l <br />330 GAL. DRILL CUTTINGS PUMP DOWN from 773 feet to 202 feet <br />12 -501f SACS (HIGH SOLIDS BENTONITE) PUMP DOWN from 202 feet to 10 feet <br />PORTLAND TYPE 11 CEMENT PLUG A 10' AND BACKFILL from 10 feet to 0 feet <br />Intervals of casing removed/ripped In feet from feet to feet <br />Report must be signed or name entered by person who performed the well plugging work or by the well owner lithe person is unknown or <br />not reachable 1 (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Date (mm/dd/yyyyy) <br />It is the responsibility of the well owner to have the weWhole properly plugged and sealed. The Well Construction Contractor <br />is responsible for notifying the owner of ttds requirement. <br />