Free GWS-09, WELL ABANDONMENT REPORT - Colorado

6/2006 Information and Standards Conditions of approval of a replacement well permit generally require that the old well be plugged and sealed according to the Water Well Construction Rules. A blank report form is provided to the well owner when a replacement permit is issued. This report is also used to affirm that other types of wells and holes have been plugged and sealed. These reports must be completed and submitted to the Division of Water Resources, usually within 90 days of plugging and sealing the well/hole. This form may be reproduced by photocopy or word processing means. STANDARDS FOR PLUGGING, SEALING, AND ABANDONING WELLS AND BOREHOLES 16.1 General - The plugging, sealing and abandonment of all wells, monitoring and observation wells, monitoring and observation holes and test holes that are no longer intended for use, and the plugging, sealing, and abandonment of dry holes, collapsed or unusable boreholes, and other incomplete wells or excavations is necessary to prevent contamination of ground water and the migration of water through the borehole. It is the ultimate responsibility of the well owner to have an existing well properly plugged, sealed and abandoned. The well construction contractor or authorized individual is responsible for notifying the well owner in writing of these plugging requirements. 16.1.1 In the event a borehole(s) is not completed for the intended purpose, the contractor will notify the well owner of the well owner's responsibility for the proper abandonment of the borehole(s) according to Rule 16.1. If the well owner does not agree to allow the contractor to abandon the borehole(s), the contractor shall notify the Board of Examiners, in writing, of the existence of the borehole(s) and the contractor's effort to notify the well owner of the well owner's abandonment responsibilities under Rule 16.1 16.1.2 Persons authorized to install pumping equipment may plug, seal and abandon wells that do not require the removal of casing that penetrates more than one aquifer or the ripping or perforating of casing opposite confining layers. 16.1.3 Materials used for backfilling shall be clean, inert, and free from contaminants. The well casing may be cut off below land surface so that it will not interfere with the anticipated use of the land. If the casing is cut off below land surface, the uppermost five (5) feet of the remaining casing shall be filled with grout or a watertight cover shall be permanently attached to the remaining casing and the excavation shall be filled with materials that are not more permeable than the surrounding soils and adequately compacted to prevent settling. 16.2 Wells or Boreholes in Type II and Type III Aquifers - Wells completed into unconfined aquifers and unconsolidated aquifers shall be plugged, sealed and abandoned by filling the well to the static water level with drill cuttings, clean sand or clean gravel, then with clean native clays, cement or high solid bentonite grout to the ground surface. The uppermost five (5) feet of casing shall be filled with grout or a permanent watertight cover shall be installed at the top of the casing. If casing is removed, the hole shall be filled as described above to within five (5) feet of the ground surface. The top five (5) feet of the hole shall be filled with materials less permeable than the surrounding soils that are adequately compacted to prevent settling. 16.2.1 Dewatering wells, horizontal drains, monitoring and observation holes, percolation holes, piezometer holes, sumps, test holes and dry holes shall be plugged, sealed, and abandoned either pursuant to Rule 16.2 or by removing all casing that was installed and by filling the hole(s) with drill cuttings, clean native clays, cement or high solid bentonite grout to within five (5) feet of the ground surface. The top five (5) feet of the hole shall be filled with materials less permeable than the surrounding soils that are adequately compacted to prevent settling. 16.3 Wells or Boreholes in Type I Aquifers - Wells which were constructed through more than one aquifer shall be plugged and sealed by placing a cement grout plug at the confining layer above each aquifer. If records do not show that the casing opposite each confining layer has been grouted when originally installed, the casing shall be either completely removed from the hole, or perforated or ripped opposite such layer prior to placing the grout plug. Plugs shall be no less than forty (40) feet in length and shall be designed to withstand the maximum potential hydrostatic pressure differential between the aquifers. The well casing, except for the grout plug intervals, shall be completely filled to the land surface with clean native clays, cement or high solid bentonite grout. A watertight cover shall be permanently welded or attached to the top of the casing. RULE 16

If you have questions, contact the Denver or the Division Office where your well is located.
Division 1 810 9th St. 2nd Floor Greeley, CO 80631 (970) 352-8712 Fax (970) 392-1816 Division 5 Direct mail to Box 396 Glenwood Spgs CO 81602 50633 U.S. Hwy 6 & 24 Glenwood Spgs., CO 81601 (970) 945-5665 Fax (970) 945-8741 Call First Division 2 310 E. Abriendo Ave Ste B Pueblo, CO 81004 (719) 542-3368 Fax (719) 544-0800 Division 6 Direct mail to Box 773450 505 Anglers Dr. Suite 101 Steamboat Spgs, CO 80477 (970) 879-0272 Fax (970) 879-1070 Division 3 301 Murphy Drive Alamosa, CO 81101 (719) 589-6683 Fax (719) 589-6685 Division 7 701 Camino Del Rio Ste. 205 Durango, CO 81301 (970) 247-1845 Fax (970) 259-0944 Division 4 1871 East Main St. Montrose, CO 81401 (970) 249-6622 Fax (970) 249-8728 Denver Office 1313 Sherman St. Rm. 818 Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589

Form No. GWS-09 6/2006

STATE OF COLORADO, OFFICE OF THE STATE ENGINEER 821 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us

For Office Use Only

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) ________________________________________________________________ Mailing Address ___________________________________________________________ City, St., Zip ______________________________________________________________ Phone ( ) __________________________

Well (Hole) Owner:
NAME(S) _________________________________________________________ Phone ( ) _____________________________

Mailing Address, City, St., Zip ______________________________________________________________________________________ ACTUAL WELL LOCATION: County __________________________ Property Address, City, St, Zip_____________________________________________________________________________________ _____1/4 of the____ 1/4, Sec. ____, Twp. ______ Distance from Section Lines ________ Ft. From N. or N. or S., Range ______ E. or W., ____ P.M. E. or W. Line.

S., _________ Ft. From

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 or zone 13 ; 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. Other (please explain) _______________________________________________________________________________________ The well was plugged with the following materials placed at the indicated intervals:

Amount and Type of Material
___________________________________________ ___________________________________________ ___________________________________________

Method of Placement
______________________________ ______________________________ ______________________________

Interval
from _______ feet to _________ feet from _______ feet to _________ feet from _______ feet to _________ feet from _______ feet to _________ feet

Intervals of casing removed/ripped in 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. I (we) have read the statements made herein, know the contents thereof, and that they are true to my (our) knowledge. Signature(s) Please print the Signer's Name & Title Date

____________________________________ ____________________________________

_____________________________________ _____________________________________ ____________________

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.