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FORM NO. WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br /> GWS-31 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> 04/2005 1313 Sherman St.,Room 818,Denver,CO 80203 <br /> Phone-Info(303)866-3587 Main(303)866-3581 <br /> Fax 303 866-3589 http://www.water.state.co.us <br /> 1. WELL PERMIT NUMBER: <br /> 2. WELL OWNER INFORMATION <br /> NAME OF WELL OWNER: Holcim, Inc. <br /> MAILING ADDRESS: 3500 Highway 120 <br /> CITY: Florence STATE: CO ZIP CODE: 81226 <br /> TELEPHONE NUMBER: 719 784-1118 <br /> 3. WELL LOCATION AS DRILLED: SE1/4, SW1/4, Sec. 16, Twp. 19 ❑ N or® S, Range 68 ❑ E or®W <br /> DISTANCES FROM SEC. LINES: ft.from ❑ N or❑ S section line and ft.from ❑ E or❑W section line. <br /> SUBDIVISION: NA , LOT NA, BLOCK NA, FILING(UNIT)NA <br /> Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: MW-13 <br /> must be meters, Datum must be NAD83, Unit must be set to true N, ❑ Zone 12 or❑ Zone 13 Easting: <br /> STREET ADDRESS AT WELL LOCATION: Highway 120 Northing: <br /> 4. GROUND SURFACE ELEVATION feet DRILLING METHOD Air Rotary <br /> DATE COMPLETED 04/03/09 TOTAL DEPTH 32 feet DEPTH COMPLETED 30 feet <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM(in.) From ft To ft <br /> Depth Type Grain Size Color Water Loc. 5 0 32 <br /> 04 SILT silt sized It bn aray none <br /> 3-18.5' SANDSTONE med sand It gray 15-17' <br /> 18.5-32' LIMESTONE silt sized gray none 7. PLAIN CASING: <br /> OD(in) Kind Wall Size(in) From(ft) To(ft) <br /> 2-inch PVC sch.40 0 15 <br /> PERFORATED CASING: Screen Slot Size(in): 0.010 <br /> 2-inch PVC sch.40 15 30 <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material sand Type NA <br /> Size #10/20 <br /> Interval 13-32' Depth NA <br /> 10. GROUTING RECORD <br /> Material Amount Density Interval Placement <br /> Remarks: b chips bucket 1/8" 11-13' poured <br /> grout 10 gal std. 2-11' poured <br /> 11. DISINFECTION: Type none Amt. Used NA <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 15' ft. Date/Time measured:04/03/09/08:50am Production Rate NA gpm. <br /> Pumping Level NA ft. Date/Time measured NA Test Length(hrs)NA <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 and certified in <br /> 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 <br /> section 37-91-108 1 e ,C.R.S.,and is punishable by fines up to$5000 and/or revocation of the contracting license. <br /> Company Name: Phone: License Number: <br /> Mailing Address: <br /> Signature: Print Name and Title Date <br />