| Form 27/27A |  Related  Doc |
| Date Submitted: | 4/21/2022 |
| Date Recv'd: | 4/21/2022 | Assigned by: | Robert Chesson |
| DocNum: | 403017289 | API number: | 05-123-14115 |
| Document Type: | FORM 27 | Project Number: | 22912 |
| Operator Information: |
| Operator: | CRESTONE PEAK RESOURCES OPERATING LLC |
| Oper. No. | 10633 |
| Address: | 555 17TH STREET SUITE 3700 DENVER CO 80202 |
| Type Of Facility: | SPILL OR RELEASE |
| Fac. Name | Miller 4-20J |
| County Name: | WELD |
| Operator contact: | Jacob Evans |
| qtrqtr: CSE | section: 20 | township: 3N | range: 66W | meridian: 6 |
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| Remediation Details: |
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| Reason for Report: OTHER |
| Cause of Condition: OTHER |
| Potential Receptors: Residence to south with domestic well permit #252360-A |
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| HOW REMEDIATE: | As needed, site specific soil and/or groundwater remediation plans will be developed and submitted to COGCC via supplemental Form 27. |
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| INITIAL ACTION: | This form has been prepared to support removal of a wellhead and on-location flowline. In accordance with COGCC Rule 911 and Rule 915, initial representative soil samples will be collected beneath the wellhead. Initial laboratory soil analysis will include only BTEX, 1,2,4 and 1,3,5 Trimethylbenzene, naphthalene, TPH, pH, EC, SAR and boron. Soil samples collected beneath the off-location flowline will be field screened, and a lab analysis submitted if impacts are identified. Groundwater, if present, will also be collected and analyzed. Identified impacts will be reported as required for
each discovery, and a Form 19 will be submitted, and remedial investigation will be conducted with excavation equipment.
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| RECLAMATION PLAN: | Reclamation activities will be completed in accordance with 1000 Series Rules, in collaboration with the landowner, and reported in a Form 4 (Sundry Notice) with proper documentation to demonstrate compliance with requirements for final reclamation. After all road base or other material is removed for reclamation, Operator may submit samples for laboratory analysis for soil suitability in compliance with 915.b if impacts from inorganic constituents are indicated. |
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| SOURCE REMOVED: | If a suspected release is identified and confirmed through soil screening and/or laboratory analysis during decommissioning of this facility, soils may be removed and transported to a licensed disposal facility. Transport and disposal records will be kept on file under usual and customary practice and are available upon request. If all source material cannot be removed during excavation activities, additional methodologies will be proposed in subsequent Form 27 supplementals. |
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| Correspondence Log: |
| Final Resolution | | Date | Case Closed? | Letter Sent? | CECMC Person | | N/A | N | | Kari Brown | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Robert Chesson | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Alexander Ahmadian | | | N/A | N | | Kari Brown | |
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| Coordinates: |
| Type | Facility ID | Facility Name/Num | Lat/Long |
| Facility | -99999 | No Facility
1 | 40.206753/-104.796379 |
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| Remediation | 482568 | Miller 4-20J
| 40.206505/-104.796327 |
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