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Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use Only <br />GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />5/2011 (303) 866 -3581 Fax (303) 866 -3589 http: / /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- Hoie ID # /Name _ T- <br />Individual /Comoanv responsible forDluaaina and sealing the well: <br />NAME(S) - aJcmj jwV\ 1Zjxt: &V' .1yYi(LtJ8fJ` L- i!n -FeC lay <br />Mailing Address (04C� te�(� l Pte✓ lr�i �,-P <br />City, St., Zip �c�yt. .d, CC) P, (30 <br />Phone <br />Well (Hole) Owner: 1 <br />NAME n <br />S) l oltbyluc)r) (�) A Ie W-S Phone ( R70) Nfa -9215 <br />Mailing Address, City, St., Zip i7 O , �hnti 79c) ����� . C 0 Q_1 47r) <br />ACTUAL WELL LOCATION: County _1L&(v\ <br />Property Address, City, St, Zi <br />114 of the 1/4, Sec. _, Twp. ❑ N. or ❑ S., Range <br />Distance from Section Lines Ft. From ❑ N. or ❑ S., <br />❑ E. or❑ 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 13A. Units must be meters; Datum must be NAD83: Unit must be set to true north. <br />Easting 1 V- Northing 4-19 L270, _S 6 <br />I (we) report the existing well (hole) was plugged and sealed on the date of (T 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 explain) T>'��� ILA &4 <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amountsi and Type of Material I Mgthod of Placement <br />�PSC 170V`iA&A GotJerJ bly't K V' WU )Lu4i W' <br />Intervals of casing removed /ripped in feet <br />. Interval <br />from (o (2 feet to EQ feet <br />from feet to (— feet <br />from feet to Sa4a feet <br />y 1 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. I <br />(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. <br />j Please print the Signer's Name & Title <br />Date <br />X14 I i <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 />