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FORM NO. <br />GWS -31 <br />4/2012 <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St., Ste 821, Denver, CO 80203 <br />Main (303 ) 866 -3581 Fax 303 866 -3589 www.water.state.co.us <br />For Office Use Only <br />1. WELL PERMIT NUMBER: <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: Bestway Concrete & Aggregate <br />MAILING ADDRESS: 301 Centennial Drive <br />CITY: Milliken STATE: CO ZIP CODE: 80543 <br />TELEPHONE NUMBER w /area code: 970 356 7523 <br />3. WELL LOCATION AS DRILLED: NE 1/4, NW 1/4, Sec., 1 Twp? ix I N or S, I I Range 68 ❑ E or W D <br />DISTANCES FROM SEC. LINES: 1536 ft. from Ix N or I S section line and 2577 ft. from ❑ E or ❑ W section line. <br />SUBDIVISION: , LOT , BLOCK . FILING (UNIT) <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: SE <br />Easting: <br />must be meters, Datum must be NAD83, Unit must be set to true N, I Zone 12 or If I Zone 13 <br />STREET ADDRESS AT WELL LOCATION: Northing: <br />4. GROUND SURFACE ELEVATION NA feet DRILLING METHOD Hollow Stem Auqer <br />DATE COMPLETED 02/14/2014 TOTAL DEPTH 26 feet DEPTH COMPLETED 26 feet <br />5. GEOLOGIC <br />Depth <br />LOG: <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />16. HOLE DIAM (in.) From (ft) To (ft) <br />2" 0 26 <br />0 -10 <br />clay <br />fine <br />brown <br />10 -15 <br />fined grained sand <br />SP <br />brown <br />12' <br />15 -26 <br />gravel <br />coarse <br />brown <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />2" PVC 1/81, +3 10 <br />PERFORATED CASING: Screen Slot Size (in): 0.010 <br />2" PVC 1/8" 10 26 <br />26 <br />bedrock <br />fine grained <br />grey /blue <br />8. FILTER PACK: <br />Material silica sand <br />Size 10/20 <br />Interval 2 -26 <br />9. PACKER PLACEMENT: <br />Type <br />Depth <br />10. GROUTING RECORD <br />Material Amount Density Interval Placement <br />Bent 3 baqs top 2' hand <br />s -crete 2 bags top 2' hand <br />Remarks: <br />11. DISINFECTION: Type Amt. Used <br />12. WELL TEST DATA: ❑ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level ft. Date/Time measured: Production Rate gpm. <br />Pumping Level ft. Date/Time measured Test Length (hrs) <br />Remarks: <br />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 <br />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 <br />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 <br />of the contracting license. If filing online the State Engineer considers entering of licensed contractor name to be compliance with Rule 17.4 <br />Company Name: <br />Drillinq Enqineers <br />Phone w /area code: <br />License Number: <br />Mailing Address: <br />Sign (or enter name if filing online) <br />Print Name and Title <br />Mark Johnson <br />Date <br />02/14/2014 <br />