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WELL CONSTRUCTION AND TEST REPORT For Of�oe use Only <br /> G1AfS-31 <br /> FORM NO. STATE OF COLORADO,OFFICE OF THE STATE ENGINEER <br /> 04=05 1313 Shmmen SL,ROOm 818,Denver,CO 80203 <br /> Phone-kjo(303)866-3587 Main(303)866-3561 <br /> Fax 303 866-3689 httpJAAfAM-water.state.co.Us <br /> NELL PERMIT NUMBER: <br /> WELL OVIINER INFORMATION _ �J <br /> NAME OF WELL OWNER: <br /> MAILING ADDRESS: /00 16 /�7 <br /> CITY:/ 4p 6LA,65 STATE: Co ZiP CODE �Sa <br /> TELEPHONE NUMBER: �� <br /> 3. WELL LOCATION AS DRILLED I—Vk 1/4, "1/4, Sec.a$E Twp.�_ ❑Nor 0t, Range L-�_ ❑E� <br /> DISTANCES FROM SEC.LINES: _ft from jErN or S Section line and SOWS ft from ❑E or GJW section fine- <br /> LOT_. BLOCK FILING(UNIT) —To�VE <br /> Owner's Well Desig�thOn: <br /> Optional GPS Location:GPS Unit must use the following settings: Format must be UTM,Units Ewing: syaa <br /> must be meters,Datum must be NAD83,Unit must be set to true N, ❑Zone 12 or akf6ne 13 Northing' <br /> STREET ADDRESS AT WELL LOCATION: LL <br /> 4. GROUND SURFACE ELEVATION 9a�_feet DRILLING METHOD ROck <br /> DATE COMPLETED -��/� TOTAL DEPTH o?O'O feet DEPTH COMPLETED feet <br /> HOLE DIAM m From ft To ft <br /> . GEOLOGIC LOG: � <br /> DeW <br /> 0 <br /> T Grain Size Color Water Loa <br /> lib 1/s0 7. PLAIN CASING <br /> OD(n) Kind Wall Size(in) From(ft) To(ft) <br /> P F CASING- Screen Slot Size(in):36C- <br /> 8. FILTER PACK 9. PACKER PLACEMENT: <br /> Material Type <br /> Size Depth <br /> Interval <br /> 0. GROUTING RECORD <br /> aterial Density Interval Placement <br /> R � <br /> j/`I/5 /S 4 11 6A)/7�f�iN6 W LdWP 2 UN -- <br /> N�° <br /> 11. DISINFECTION: T �'Used <br /> 12 WELL TEST DATA Check box if Test Data is submRted on Form Number GWS 39 Supplemental Well T <br /> TESTING METHOD <br /> Static Level ft Date/Tune measured: Production Rate 9Wn <br /> Pumping Level ft DatelTime measured Test Length <br /> �o�v <br /> Remarks: Wi4 T2 true rry lviowtedye. This d«urrier4 signed af,a <br /> 13. 1 Have the ite�ein and IQ�ow oonieras aid>� a ttaa oonfair�s fates is a vWafim of <br /> with Rule 17.4 of the VMaler Well COrastnxon RUles,2 CCR 402 2 [The tSg . <br /> 1 e C.R.S. ant is fines to VI <br /> rig <br /> . 37-91-1 <br /> �parn Name: v� �� c_ 30.3 4 -�3-23 N <br /> MaiN ,4cldress: <br />