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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: 970 587 7277 <br />3. WELL LOCATION AS DRILLED: SE 1/4, NE 1/4, Sec., 1 Twp? Ix N or S, I I Range 68 ❑ E or W 0 <br />DISTANCES FROM SEC. LINES: 2755 ft. from i N or Ix S section line and 730 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: <br />must be meters, Datum must be NAD83, Unit must be set to true N, f I Zone 12 or I' 1 Zone 13 Easting: <br />STREET ADDRESS AT WELL LOCATION: Northing: <br />4. GROUND SURFACE ELEVATION NA feet DRILLING METHOD <br />DATE COMPLETED 04/16/2014 TOTAL DEPTH 44 feet DEPTH COMPLETED 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 />4" 0 44 <br />0 -3 <br />top soil <br />fine <br />brown <br />3 -22 <br />clayey sand <br />fine to coarse <br />brown <br />3' <br />2240 <br />coarse gravel <br />coarse <br />brown <br />7, PLAIN CASING: - <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />2" sch 40 _154 0 20 <br />PERFORATED CASING: Screen Slot Size (in): 10 slot <br />2" sch 40 .154 20 44 <br />4044 <br />coarse gravel <br />coarse <br />brown <br />8. FILTER PACK: <br />Material sand <br />Size 10 -20 <br />Interval 14 -40 <br />9. PACKER PLACEMENT: <br />Type <br />Depth <br />10. GROUTING RECORD <br />Material Amount Density Interval Placement <br />bent 7 baps 100pcf 0 -14 <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 />N/A <br />Mailing Address: <br />Sign (or enter name if filing online) <br />Print Name and Title <br />Date <br />