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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 htip: / /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 /Companyt responsible for olugging and seahngrrthe well: <br />NAME(S) �r uAlInrA �rw`tIQVp' .T1iCY�t."P,r (;P�i .PL�� <br />Mailing Address 4-C( e,- <br />City, St., Zip G <br />Phone ( t'4 ) a sci 509.E <br />Well (Hole) Owner: <br />For Office Use Only <br />NAME(S) Ny,.J" (�. W - ��P-IcI-� Phone ( q70 ) <br />Mailing Address, City, St., Zip 17 c,k F�; keds2ti C0 2. 4-Tp <br />ACTUAL WELL LOCATION: County S, V\ Zu1A <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. 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 1:1 or zone 13 X Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />Easting 6SZ.4.0 Northing hr ��52�` ,7 3 <br />I (we) report the existing well (hole) was plugged and sealed on the date of R , I I f l for the following reason(s): <br />❑ The well was plugged and sealed as required under Well Permit Number _ 1� <br />❑ The well was not in use and was plugged and sealed. r <br />Other (please explain) TeS-- Y=JrNM u '?Iy uucyt°c] 5t'Ci�♦?c�1jr raLAW <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material 11 I llMethod of Placement <br />7i°�-� �iv�u uuPs �k.utvtu Cu.ue ✓� Wit1nClUt;(w 1 <br />1 y it `1 rf <br />7_ VAIIA U. i oUjp aua v . W"4 -eVial . rXJJtn —�a P <br />Interval St-74Z- <br />from CU feet to feet <br />from ``ZS- feet to I Q feet <br />from 1 b feet to Su✓ eet <br />Intervals of casing removed /ripped in feet v 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) have 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 <br />.-fie✓ ��. �. <br />It is the re4ponsibility 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 />