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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 httn: / /www.water.state.co.us <br />- -- ---- - - - - -- <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 responsible for plugging andttsealing the well: <br />NAME(S) T)L,LtlL1 �(�� Imt,- lWFV- Gec,�2r.�n <br />Mailing Address IIF c In l eu LtIC h6 kC <br />City, St.,Zip a. [AX c). C0 P, ISo <br />Phone <br />Well (Hole) Owner: } b A ` 2 <br />NAME(S) \ o VIVA C) C) Phone ( r 0 , t't� � Z Q J <br />Mailing Address, City, St., Zip �. ©. l�c, x 77c(o tuu { m a) P, (Q to <br />ACTUAL WELL LOCATION: County Stew - W-41A <br />Property Address, City, St, Zip <br />1/4 of the 1/4, Sec. _, Twp. ❑ N. or ❑ S., Range ❑ E. or W., _ P.M. <br />Distance from Section Lines Ft. From ❑ N. or ❑ 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 ❑ or zone 13K. Units must be meters; Datum must be NAD83; Unit must be set to true north. <br />Easting Northing L 171 . F <br />I (we) report the existing well (hole) was plugged and sealed on the date of for the following reason(s): <br />❑ Thewell 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) <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material Method f Placement Interval <br />J i LL\\ / f rom a feet to feet <br />r u 1 from .90 feet to — D feet <br />4-sd l f ✓`t t vy, tremmI e- -LIA Le J from 0 feet to v��TA( feet <br />Intervals of casing removed /ripped in feet from feet to feet <br />—— -- __-------- - - - - -. - - - - -- - -- _ -- - - ___ _ _ __ - -- ----._..__-_.-- <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 lead 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 />Date <br />El4 i l <br />It is the re6ponsibility 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 />