2013-08-26_HYDROLOGY - M1980244 - Laserfiche WebLink

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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 4/2012 (303) 866 -3581 Fax (303) 866 -3589 dwrpermitsonlineCa)state.co.us WELL ABANDONMENT REPORT Use to report plugging and sealing of permitted wells, monitoring and other holes This form can be computer generated, typed or printed 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- 44171 Hole ID # /Name GVMW -17B -105 Individual /Company responsible for plugging and sealing the well: Name(s) Cripple Creek & Victor Gold Mining Co. /Marc Tidquist Mailing Address P.O. Box 191 City, St, Zip Victor, CO 80860 Phone (area code & no ) 719- 689 -4056 Email- mtidquist @anglogoldashantina.c(+ Well (Hole) Owner: NAME(S) Cripple Creek & Victor Gold Mining Co. Phone (include area code) 719- 689 -4056 Mailing Address, City, St., Zip P.O. Box 191; Victor, CO 80860 ACTUAL WELL LOCATION County Teller Property Address, City, St, Zip 2755 State Highway 67; Victor, CO 80860 SW 1/4 of theme 1/4, Sec 17 , Twp 15 F N. or I] S., Range 69 M E or I] W., 6th P M Distance from Section Lines Ft. from rR7 N. or F7 S , Ft. from ❑E or x❑ 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 M or zone 13 M, Units must be meters; Datum must be NAD83; Unit must be set to true north. Easting Northing I (we) report the existing well (hole) was plugged and sealed on the date of 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. 0 Other (please explain) Area approved by DRMS for disturbance under Amendment No. 9 & 10 to Permit M1980 -244. The well was plugged with the following materials placed at the indicated intervals. Amount and Type of Material Method of Placement Interval "Well is in mine footprint - to be mined full depth from feet to feet from feet to feet from feet to feet Intervals of casing removed /ripped in feet from feet to feet Report must be signed or name entered 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. Sign or enter full name If signing print name & title Date (mm /dd /yyyyy) Marc A. Tid uist - Sr. Environmental Coor. q &2 912 2- Zc::1y.3 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.