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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br />GWS -09 821 Centennial Bldg., Sherman St, Denver, CO 80203 — <br />4/2012 (303) 866 -3581 Fax (303) 866 -3589 dwrpermitsonline(aD_state.co us _JI <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes. This form can be <br />computer generated, typed or printed in black or blue ink Instructions and plugging standards are on <br />reverse side of form <br />Well Permit Number of the well being plugged or <br />MH File Number MH- Hole ID # /Name AF-2- <br />Individual /Company responsible for plugging and sealing the well: <br />Name(s) k ER R C� L C O M PA X YX <br />Y <br />Mailing Address f3C, C z)x <br />City, St., zip <br />Phone (area code & no) 7/ Y 2?V- L--3 5 Email <br />Well (Hole) Owner <br />NAME(S) DC'I6-LOG t)APW E-TT Phone (Include area code) <br />Mailing Address, City, St, Zip It -3 MMA/sT% FD AT M0RZ,7 A nl, CC—) 7D/ <br />ACTUAL WELL LOCATION County <br />Property Address, City, St, Zip / M lLE � ; H F tti1 f�LCa'�N1 GvLe,2/�17G — <br />St 1/4 of theme 1/4, Sec. 29, Twp �_ K N. or ❑ S, Range 7 7 El E or 0 W., Ei\/C1!1 <br />Distance from Section Lines Ft from F, N or F S , Ft from ❑E or Cj W. Line �/ ``L% <br />Subdivision Name Lot Block JUN 0 3 2013 <br />, Filing /Unit <br />Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows DM,9CN OF <br />RECLAMATION <br />Format must be UTM, zone 12 r' or zone 13 F] , Units must be meters; Datum must be NAD83; Unit must be seWN&A WETY I <br />Easting Northing / 0 700 <br />I (we) report the existing well (hole) was plugged and sealed on the date of 1 for the following reason(s): <br />❑ The well was plugged and sealed as required under Well Permit Number <br />❑ The well was not in use and was plugged and sealed <br />Other (please explains Co L-OA ADO <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Ty p of Material Method of Placement ; t� Interval <br />C, f G • 'Ab 5 �+�! L� F g J c� ' c�yl� J ,ll G r� �3 •`h �� from 3 feet to �_ feet <br />,AX7 C A!,/ Q� 3 h Q e U 1�'� ��% ji {' ���'� 7 f from feet to feet <br />S c k` S �1�' Q m C' �a���'��/� from feet to feet <br />/ /qo <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 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 />Sign or enter full name If signing print name & title Date (mm /dd /yyyyy) <br />ZJ- <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 />