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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />5/2011 (303) 866 -3581 Fax (303) 866 -3589 httn: / /www.water.state.co,us <br />WELL ABANDONMENT REPORT <br />Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or <br />print in black or blue ink. Instructions and plugging standards are on reverse side of form. <br />Well Permit Number of the well being plugged or <br />MH File Number MH- Hole ID #/Name — <br />Individual /Company -rresponsible for 0uaaina and sealina the well I: 1 t <br />NAME(S) ��11� I� a 1 1� T .tAw. -r C..'ey <br />Mailing Address �4 I e�ln �e � bV,i t,P <br />City, St., Zip /1L <br />Phone ( q7o ) g Gc�— o� <br />Well (Hole) Owner: <br />For Office Use Only <br />NAME(S) Ul�o C-)0(a OrS �(�jlu -Ci I Phone ( �7 /)� �q ^k(- q2%- -J <br />Mailing Address, City, St., Zip L�lc T t o <br />ACTUAL WELL LOCATION: County Sv11LA <br />Property Address, City, St, Zip <br />1/4 of the 1/4, Sec. _, Twp. ❑ N. or E] S., Range <br />Distance from Section Lines Ft. From ❑ N. or ❑ S., <br />❑ E. orb W., _ P.M. <br />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 ❑ or zone 13) Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />Easting 2 , Northing � 19 A�2? . _I ' <br />I (we) report the existing well (hole) was plugged and sealed on the date of �7 for the following reason(s): <br />F-1 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 explain) If-4Z Zrwba S4 :PL <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Meth ?d of Placement <br />Interval <br />from +5 feet to t=L feet <br />tbvtC [ )QL A — 11w � to from -L" I? feet to I L) feet <br />G 0)e)LVtn — VV- I Q from 10 feet to Meet <br />Intervals of casing removed /ripped in feet v I from feet to feet <br />Report must be signed by person who performed the well plugging work or by the well owner if this person is unknown or not reachable. <br />(we) havq read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />Please print the Signer's Name & Title I Date <br />1 14:111 <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 />