2013-06-24_REPORT - P2011015

• Permit No: P2011015
• IBM Index Class Name: REPORT
• Doc Date: 6/24/2013
• Doc Name: ANNUAL FEE/REPORT
• From: OPERATOR
• To: DRMS
• Email Name: WHE
• Media Type: D
• Archive: No

Form No. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
5/2011 (303) 866 -3581 Fax [phone] htti2://www.water.state.co.us
WELL ABANDONMENT REPORT
Use to report plugging and sealing of permitted wells, monitoring and other holes. Type or
print in black or blue ink. Instructions and plugging standards are on reverse side of form.
Well Permit Number of the well being plugged or
MH File Number MH- Hole ID # /Name
Individual /Company responsible for plugging and sealing the well:
NAME(S)
Mailing Ad
For Office Use Only
City, St., Zip
Phone ( �o �5�1- S oo( S
Well (Hole) Owner: �♦
NAME(S) C-0 0 J n Phone
Mailing Address, City, St., Zip 0 - �0k ( t eAQLA
ACTUAL WELL LOCATION: County S,V\ _Tw VV\
Property Address, City, St, Zip
1/4 of the 1/4, Sec. _, Twp. ❑ N. or F-1 S., Range
Distance from Section Lines Ft. From ❑ N. or ❑ S.,
❑ E. or❑ W., _ P.M.
Ft. From ❑ E. or ❑ W. Line.
Subdivision Name Lot , Block , Filing/Unit
Optional: GPS well location information in UTM format. You must check GPS unit for required settings as follows:
Format must be UTM, zone 12 ❑ or zone 139. Units must be meters; Datum must be NAD83; Unit must be set to true north.
Fasting ; �. - 14 Northing 4-19 S L Lt. 4
I (we) report the existing well (hole) was plugged and sealed on the date of lan I( I— for the following reason(s):
❑ The well was plugged and sealed as required under Well Permit Number
❑ The well was not in use and was plugged and sealed.
Other (please explain) TPA{-jrl�n�T�
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type of Material Method
Me thod of Placement Interval
l�r%r4AN CUU•e r) Auvl i O W Clu G P ✓' W i t(A.GAA OAJ
1 from SS feet to zL' ",3 feet
1"
un
Intervals of casing removed /ripped in feet
V Ik
from IS feet to feet
from ( 0 feet to feet
from feet to feet
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
(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
print the Signer's Name & Title
Date
P --�
ev--, j I �
It is the responsibility of the well owner to have the well /hole properly plugged and sealed. The Well Construction Contractor
is responsible for notifying the owner of this requirement.