2014-03-26_REPORT - M2009018

• Permit No: M2009018
• IBM Index Class Name: REPORT
• Doc Date: 3/26/2014
• Doc Name: Acord complaint CT01
• From: Awes, LLC
• To: DRMS
• Type & Sequence: CT1
• Email Name: PSH
• Media Type: D
• Archive: No

FORM N0,
GWS -31
4/2012
WELL CONSTRUCTION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St., Ste 821, Denver, CO 80203
Main 303 866 -3581 Fax [phone] www.water.state.co.us
For Office Use Only
RECEIVE
DEC 2 0 2013
WA7E r,,
STATE
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1. WELL PERMIT NUMBER: _
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: ACORD ST VRAIN VALLEY RANCH LLC
MAILING ADDRESS: 7541 CR 26 3/7
CITY: LONGMONT STATE: CO ZIP CODE: 80504
TELEPHONE NUMBER w /area code: 303 - 776 -2112
3. WELL LOCATION AS DRILLED: NE 114, NW- 1/4, Sec., 32 Twp 3 Gi N or S, ❑I Range 67 E1 E or W El
DISTANCES FROM SEC. LINES: ft. from ❑ N or ❑ S section line and ft. from [2 E or 0 W section line.
SUBDIVISION: , LOT , BLOCK FILING (UNIT)
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owners Well Designation:
must be meters, Datum must be NAD83, Unit must be set to true N, ❑1 Zone 12 or ]c] Zone 13 Easting: 507293
STREET ADDRESS AT WELL LOCATION: Northing: 4448676
4. GROUND SURFACE ELEVATION feet DRILLING METHOD ROTARY
DATE COMPLETED 12/12aOl 3 TOTAL DEPTH 30 feet DEPTH COMPLETED 30 feet
5. GEOLOGIC LOG:
6. HOLE DAM in. From ft To ft
Depth
Type
Grain Size
Color
Water Loc.
9 0 30
0-4
TOP SOIL
4 -20
SAND /GRAVEL
FINE- 3/4
20 -30
SAND /GRAVEL
FINE - ROCK
XXXX
7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
6518 STFFI 1.8A +1 20
PERFORATED CASING: Screen Slot Size (in): .030
41/2 PVC .250 20 30
8. FILTER PACK:
Material GRAVEL
Size 3/8
Interval 20 -30
9. PACKER PLACEMENT:
Type
Depth
_
0. GROUTING RECORD
Material Amount Density Interval Placement
CEMENT 3SKS 1.86 0 -20 POS DISPL
Remarks:
11. DISINFECTION: Type STERILENE Amt. Used 4 OZ
12. WELL TEST DATA: ❑ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test,
TESTING METHOD AIR LIFTED /OVER PUMPED
Static Level 10 ft. Date/Time measured: 12/12/2013 Production Rate 15 gpm.
Pumping Level 21 ft. Date/Time measured 12/12/2013 Test Length (hrs) 4
Remarks:
13. 1 have read the statements made herein and know the contents thereof, and they are true to my knowledge. This document is signed (or
name entered if filing online) and certified in accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402 -2. The filing of a
document that contains false statements is a violation of section 37- 91- 108(1)(e), C.R.S., and Is punishable by fines up to $5000 and/or revocation
of the contracting license. If filing online the State Engineer considers entering of licensed contractor name to be compliance with Rule 17.4
Company Name:
QUALITY WELL AND PUMP
Phone w /area code:
970 - 353 -3118
License Number:
1461
Maflinq Address -2327 U WY 85 LA SALLE, CO 80645
Sign (or enter ame f g online) Print Name and Title
CHRIS JONES, OWNER
Date
12/17/2013