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 For Office Use Only
GWS -09 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
5/2011 (303) 866 -3581 Fax [phone] hltp: / /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) , l,luX+Acy-
Mailing Address b +C1 7r?r� C,CAt✓- INNi
City, St., zip -.".,All 1��. L U _ iy0
Phone SOR
------ - - - - -- - - - -- ------------------------ - - - - -- - - - - - --
Well (Hole) Owner: rp� ii
NAME(S)..- jn^k J 1�" � l 0l "e-la& ." ly1(,. Phone ( rJ ) it 6 " R �+S
Mailing Address, City, St., Zip �_O_) ?jam t) -<JLednkA CIP R Aac)
ACTUAL WELL LOCATION: County Suva JL4c,v1
Property Address, City, St, Zip
1/4 of the- 1 /4, Sec. _, Twp. ❑ N. or ❑ S., Range
Distance from Section Lines Ft. From ❑ N. or ❑ S.,
Subdivision Name
Optional: GPS well location information in UTM format.
Format must be UTM, zone 12 E3 or zone 13 m;
Easting
Northing 't- I"[
❑ E. or❑ W., _ P.M.
Ft. From ❑ E. or ❑ W. Line.
Lot , Block , Filing /Unit
You must check GPS unit for required settings as follows:
Units must be meters; Datum must be NAD83; Unit must be set to true north.
I (we) report the existing well (hole) was plugged and sealed on the date of 1 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. 1 I
.Other (please explain) e.S (At�int 7y din E I 4
The well was plugged with the following materials placed at the indicated intervals:
Amount and Type of Material Method of Placement
_ieuyt W W ( n t cck;,4'e it
r lr I �ec� C6111n- 1� _
IX
kim yu -. 3 -1 -
Intervals of casing removed /ripped in feet 'A
Interval _
from -t feet to 1 n feet
from feet to d feet
from feet to si.!Olvtdefeet
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.
(we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge.
Please print the Signer's Name 8 Title Date
(tq
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.