| Agency | Form: (02 )
1698518
7/19/2010 | (1) COMPLY WITH NOTIFICATION REQUIREMENTS OF THE MOST CURRENT VERSION OF THE NORTHWEST COLORADO NOTIFICATION POLICY.
24-HOUR NOTICE TO MOVE ON LOCATION REQUIRED. E-MAIL Mike.Longworth@state.co.us
ALSO E-MAIL: Shaun.Kellerby@state.co.us
(2) CEMENT-COVERAGE VERIFICATION BY CBL REQUIRED FOR NEW HOLE SECTION(S).
(3) APPROVAL OF THIS FORM DOES NOT AUTHORIZE INJECTION. AUTHORIZATION TO INJECT REQUIRES APPROVAL OF FORM 31 AND FORM 33.
(4) THE PRESENT SURFACE CASING IS MORE THAN 50’ BELOW THE DEPTH OF THE DEEPEST WATER WELL WITHIN 1-MILE OF THE SURFACE LOCATION WHEN CORRECTED FOR ELEVATION DIFFERENCES. THE DEEPEST WATER WELL WITHIN 1-MILE IS 00 FEET DEEP.
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