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FORM NO WELL CONSTRUCTION AND TEST REPORT For Office use Only <br /> GUYS-31 STATE OF COLORADO.OFFICE OF THE STATE ENGINEER <br /> 04/2005 1313 Shemtan St.,Roan 818.Denver.CO 80203 <br /> Phone-Into(303)8W-3587 Man(303)866-3581 <br /> Fax 303 866-3589 :/Mww-water.state.Co.Us <br /> — WELL PERMIT NUMBER: a?$R 78 <br /> WELL OWNER INFORMATION Y,/ <br /> NAME OF WELL OWNER: &7V77(967 <br /> MAILING ADDRESS: -0 60 X ?7 <br /> City: //*S STATE.CO ZIP CODE: tW S <br /> TELEPHONE NUMBER: 303 - e,32 3 <br /> 3. WELL LOCATION AS DRILLED: S91/4, 5W 114, Sea_6 - Twp. ❑N or l�Range -73 ❑E or g'W <br /> DISTANCES FROM SEC.LINES: �_ft from ❑N or OWsesection late and 60-7 _ft from ❑E or Ga'w section fine. <br /> SUBDIVISION: LOT. BLOCK FILING(UNIT) <br /> Optional GPS Location:GPS Unit must use the following settings: Format must be UTM,Units Ownees Web �g nation a �frZ <br /> must be mebars,Datum must be NAD83,Unit must be set to true N, ❑Zone 12 or❑done 13 Eas": y�.SS <br /> STREET ADDRESS AT WELL LOCATION: Nalhhn <br /> . GROUND SURFACE ELEVATION S60 feet DRILLING METHS <br /> DATE COMPLETED --O TOTAL DEPTH o feet DEPTH COMPLETED ao, feet <br /> 5. GEOLOGIC LOG: S. HOLE DIAM(in.) From ft To ft <br /> T Grain Size Color Water Loa .' 6'offDepth C7 ao�D <br /> p-// tv&".6AW Y <br /> r-$/ If S i i <br /> i� <br /> i-ap f7Z�- &WOe44k it D o 7. PLAIN CASING: <br /> , Kind- WW 11�Size(in) From(ft) T3� <br /> PERFORATEDCASING: Screen Slot Size(in): i <br /> ��'" 3, <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material Type <br /> Size <br /> Interval Depth <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br /> Remadw 1---=-- <br /> 7,#5 /S A /'�NiTA�ndG 'Lr/ L Fof2 A <br /> 11. DISINFECTION: IM Amt Used <br /> 12 WELL TEST DATA 0 Check box if Test Data is submitted on Form Number GWS 39 SupPlemerd2l WeN Test <br /> TESTING METHOD <br /> Static Level ft Datw Twm measured: Production Rate 9Pm <br /> Pumping Level ft Date/Tune measured - Test Length fts) <br /> Remarks: Lea 1ycwlT�,erN6 O/UG <br /> 13. 1 gave read The oaft made hwm and krt w the cwft is thereof,and they are true to my IknordaMe. This doetment is signed and CerGTred n <br /> acmdance with Rule 17.4 of the Weder WeB C0r6WJCfi0n Rules,2 CM 402-1 [The MV of a domwm t that contains false swwwft is a violation of <br /> secoon 37 91-1 1 e C.R.S. and is fines to i5000 andfar revocaation of the 7�3 <br /> y"a"� 6 i /� /LC /�C- 303 o 3 <br /> Mailing Andress: �X /97(,, /Vifh6 5V/7/NGS co-$0 fT,�-- <br /> e: "�'"e an f(ffGE <br />