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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- Hole ID # /Name KA C,--t <br />Individual /Company responsible for plugging and sealing the well: <br />NAME(S) ITcXAu�� . 1 V` . � VtAEA A�'V` C' C�teG <br />Mailing Address C07'-( le-c,� CgM i-cC — <br />City, St., Zip <br />Phone ('I L V)So(— C►q <br />Well (Hole) Owner: 1 r A 2 <br />NAME(S)Co . �n C,,60 tielr)S II Phone ( ) 94('924 -S <br />Mailing Address, City, St., Zip -P.(), <br />x �4� S ll tbt/� i �� + Q 2 <br />ACTUAL WELL LOCATION: County. SCIO 4 r. <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 1:1 or zone 13 Units must be meters; Datum must be NA083; Unit must beset to true north. <br />A <br />Easting 2 ;3 N4 U Northing 4 9 i% -J . L lfi <br />I (we) report the existing well (hole) was plugged and sealed on the date of �?_Z 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) Test�tvt� <br />The well was plugged with the following materials placed at the indicated intervals: <br />Amount and Type of Material , Method of Placer <br />d + <br />"UAWt,t -e Ll C V <br />Intervals of casing removed /ripped in feet <br />. Interval <br />from A00 feet to ! , feet <br />6m,— A feet to 1_ feet <br />from 10 feet to Su c „feet <br />from feet to feet <br />Report my_g 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 />It is the restponsibility of the well owner to have the well /hole properly plugged and sealed. The Well Construction <br />is responsible for notifying the owner of this requirement. <br />