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Dorm No. <br />GWS-09 <br />4/2012 <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br />821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />(303) 866-3581 Fax ( 303) 888 -3589 dwrpermitsonlinedi)atata_co.us <br />WELL ABANDONMENT REPORT <br />Use to report pugging and sealing of pemdaed wells, mcndwing and other holes This form can be <br />computer generated, typed or printed VI bled( or blue ink Ineliucdone and plugging standards we on <br />r vemme Aide of form. <br />Well Permit Number of the well being plugged <br />MH File Number MH- Hole ID *Name B12 -7 <br />Individual/Company responsible for oluocaina and sealing the well: <br />Nauw(a) GODBE DRIWNG LLC. <br />Melting Address 62802 OHLM ROAD <br />City, St, zip MONTROSE, CO, 81403 <br />Phone (area code & no.) 970 - 240 - 6106 Emai: jjgodbe@aol.com <br />Well (Hole) Owner, <br />NAME(s) GOLD HILL MINERALS Phone (include area code) 305-726 -7752 <br />Mailing Address, City, St, Zip PO BOX 191127, MIAMI BEACH, FL, 33119 -1127 <br />ACTUAL WELL LOCATION: County BOULDER <br />Property Address. CO. St LIP 3G 3 J 04er 1ANa Rd, P)f €s4�isA/.M C.6 701St <br />,hE1/4 of thef W 1/4, Sec.z`f Twp. N. or 0 S., Range 7_2 0 E. or DI W., lam P.M. <br />Distance from Section Lines 2033 A Ft. from ❑ N. or C S., t,fada Ft from DE. or p W. 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 />Fofmat must be UTM, zone 120 or zone 13 I1 , Units must be ureters, Datum must be NAD83: Unit must be set to true north. <br />Easting 415,33 9 Northing j 641 l )S 1- <br />I (we) report the eadsting well (hole) was plugged and sealed on the date of 10/02/2012 for the following reason(s): <br />C1 The well was plugged and sealed as required under Well Permit Ntxnber <br />❑ The well was not in use and was plu4ged and sealed. <br />III Other (pisase explain) CORE DRILL BORE HOLE ( ALL CASINGS REMOVED) <br />7 -50# SACS (HIGH SOLIDS BENTONITE) <br />PORTLAND TYPE 11 CEMENT <br />Sign or enter full name <br />The well was plugged wroth the following materials placed at the indicated Intervals. <br />Amount and Type of Material Method of Placement <br />280 GAL DRILL CUTTINGS PUMP DOWN <br />PUMP DOWN <br />Interval <br />from 511 feet to 106 <br />from 106 feet to 10 <br />PLUG a 10` AND BACKFILL from 10 feet to 0 feet <br />Intervals of casing removedhipped in feet from feet to feet <br />Report Rlust be signed or name entered by person who performed the well plugging work or by the well water if this person is unknown or <br />not reachable. I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />If signing print name & title , Date (mm/dd/yyyyy) <br />BRIAN MANTEI GODBE DRILL FOREMAN <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 <br />10/02/2012 <br />