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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER l <br />GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />4/2012 (303) 866 -3581 Fax (303) 866 -3589 dwrpermitsonIine(g. state. co us <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 AP-/ <br />Individual /Company responsible for plugging and sealing the well - <br />Name(s) k1=(Z2 aAL /C// OkI PA I:V <br />Mailing Address P6 <br />City, St., Zip FI- DR =JUc- CE1, 60 22� <br />Phone (area code & no.) 7/1 7S V &3'/5 Email- <br />Well (Hole) Owner: <br />For Office Use Only <br />NAME(S) D0Lr:,.,1-a4 S t_ ,A- R,Vr-_T 11 Phone (include area code) <br />Mailing Address, City, St., Zip //.3 1(IAI V 5T, F-7, MCRCA G� P r,-7cj P <br />ACTUAL WELL LOCATION County SAC -Ksoa <br />Property Address, City, St, Zip / MILT= Puri N of UALD"' CDL &RA Do <br />5E _1/4 of thee. 114, Sec 2�y Twp Cl R N or ❑ S , Range � E. or [Z W., t L P. M. <br />Distance from Section Lines Ft from r, N or I— S , Ft from ❑E. or ❑ 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 />Format must be UTM, zone 12 r or zone 13 M, Units must be meters; Datum must be NAD83, Unit must be set to true north. <br />Easting 2d29d Northing Ammo /t yco <br />I (we) report the existing well (hole) was plugged and sealed on the date of 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 />J� Other (please explain) COL&RADc DRIA S PF-,M 1T A 0. CRC _00C, <br />The well was plugged with the following materials placed at the indicated intervals. i I <br />A ount and Type o Material ) Method of Placement 7n¢ Interval <br />a,,,^ G L- ' c� �o� h r/ S' 1-d7 <i P i P� ? f �v : 1 /f /�L d from feet to �_ feet <br />/ g G ` J C' Iz 4-" v, 74 O % o a 19 �' �j from feet to feet <br />IJ <br />(� l / 4 / g `-� ' I from feet to feet <br />Intervals of casing remove8/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 />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 />