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INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT Rev 0412005
<br />The report must be typed or printed in BLACK OR BLUE INK. All changes on the form must be initialed and dated. Attach additional sheets if
<br />more space is required. Each additional sheet must be identified at the top by the well owner's name, the permit number, form name /number
<br />and a sequential page number. Report depths in feet below ground surface.
<br />This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State Engineer. Photocopy
<br />reproductions must retain margins and print quality of the original form.
<br />The original form must be submitted to the State Engineer's Office within 60 days after completing the well or 7 days after the permit
<br />expiration date, whichever is earlier.
<br />A copy of the form must be provided to the well owner.
<br />ITEM INSTRUCTIONS: (numbers correspond with those on the front of this form)
<br />1. Complete the Well Permit Number in full.
<br />2. Fill in Name and Mailing Address of Well Owner where correspondence should be sent.
<br />3. Complete the blocks for the actual location of where the well was drilled. If the owner has more than one well serving this property,
<br />provide the identification (Owner's Designation) for this well. For wells located in subdivisions, the name, lot, block, filing, and street
<br />address must also be provided. An option to providing distances from section lines is to provide an accurate GPS location in GPS
<br />format. The required GPS unit settings must be as indicated on this form.
<br />Colorado contains two (2) UTM zones. Zone 13 covers most of Colorado. The boundary between Zone 12 and Zone 13 is the 108th
<br />Meridian (longitude). West of the 108`h Meridian is UTM Zone 12 and east of the 108th Meridian is UTM Zone 13. The 108th Meridian is
<br />approximately 57 miles east of the Colorado -Utah state line. On most GPS units, the UTM zone is given as part of the Easting
<br />measurement, e.g. 1270123456. Check the appropriate box for the zone.
<br />4. Report the ground surface elevation in feet above sea level if available. This value may be obtained from a topographic map. Describe
<br />the drilling method used to construct the well and the date completed. Indicate the total depth and the actual completed depth of the
<br />well.
<br />5_ Fully describe the materials encountered in drilling. Do not use formation names unless they are in conjunction with a description of
<br />materials.
<br />Examples of descriptive terms include:
<br />Type — sandstone, sand, etc.
<br />Grain size — Boulders, gravel, sand, silt, clay, etc.
<br />Color — All materials, most critical in sedimentary rock
<br />Water Location — Depth when water is encountered (if it can be determined)
<br />6. Provide the diameters of the drilled borehole.
<br />7. The outside diameter, kind, wall thickness, and interval of plain and perforated casing lengths must be indicated. For perforated casing,
<br />the screen size must be indicated.
<br />S. Indicate the material and size of filter pack (e.g. sand, gravel, etc.) and the interval where placed.
<br />9. Indicate the type and setting depth for any packers installed.
<br />10. The material, amount, and interval of the grout slurry must be reported. Density may be indicated as pounds per gallon, gallons of water
<br />per sack, total gallons of water used, or number of sacks used, etc. Specify the grout placement method, i.e. tremie pipe or positive
<br />placement. The percentage of additives mixed with the grout should be reported under remarks in item 5.
<br />11. Record the type and the amount of disinfection used, how placed, and the length of time left in the hole
<br />12. Report well test data as required by Rule 10.7. Spaces are provided to report all measurements made during the test. The report
<br />should show that the test complied with the provisions of the rules. If a test was not performed explain when it will be done. If available,
<br />report clock time when measurements were taken.
<br />13. Fill in Company Name and Address of Contractor who constructed the well. The licensed contractor responsible for the construction
<br />of the well must sign the report.
<br />Submit completed report to: State of Colorado, Office of the State Engineer, 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203
<br />IF YOU HAVE ANY QUESTIONS regarding any item on this form, please call the Division of Water Resources Ground Water Information Desk
<br />(303- 866 - 3587), or the nearest Division of Water Resources Field Office located in Greeley (970 -352- 8712), Pueblo (719 -542- 3368), Alamosa
<br />(719 -589- 6683), Montrose (970 - 249 - 6622), Glenwood Springs (970 - 945 - 5665), Steamboat Springs (970 -879- 0272), or Durango (970 -247-
<br />1845), or refer to our web site at httgJ /www.water.state.co.us for general information, additional forms, and access to state rules and statutes.
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