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� <br /> GWS-31FORbi WELL CONSTRUCTION AND TEST REPORT For Office Use only <br /> GWS <br /> 10/9+ STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> 1313 Sherman St.. Rm 818. Denver, CO 80203 <br /> ON& D-9sTj5vNo ',on GVMw- <br /> i WELL PERMrr NUMBER <br /> L _,JNER NAME(S) Cr%ta01e- Crime-k 4 kAc.,T- G.)A IA-\r;na CO, <br /> Mailing Address P, 8c>u )91 <br /> City, St. Zip V i c-aot-, Co 80860 <br /> Phone (7/9) <br /> 3. WELL LOCATION AS DRILLED: SE 1/4 WE 1/4, Sec. U, Twp. /S S , Range 6 9 W <br /> DISTANCES FROM SEC. LINES: <br /> ft. from Sec. line. and ft. from Sec. line. OR <br /> (e or WM' <br /> SUBDIVISION: LOT BLOCK FILING(UNM <br /> STREET ADDRESS AT WELL LOCATION: <br /> 4. GROUND SURFACE ELEVATION 9890.6- ft. DRILLING METHOD <br /> DATE COMPLETED TOTAL DEPTH SO ft. DEPTH COMPLETED SO ft. <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM. Cn.) From (ft) To (ft) <br /> Depth Description of Material (Type,Size, Color,Water Location) 0_ O Z O <br /> Z1O SO <br /> S e.e- <br /> 7. PLAIN CASING <br /> OD (in) Kind Wall Size From(ft) To(ft) <br /> p V C' 5cl-, 40 o Zo <br /> PERF. CASING: Screen Slot Size: O, oZ0 " <br /> PV G_ SC'� �6 20 so <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material S�co, 3cx r)A Type <br /> Size 10—Zo <br /> Interval 17 SO Depth <br /> lo. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br /> REMARKS: ev kc*Ae. /Z-17 <br /> 137� r a . 0-)7 -trem-,e- <br /> 1 DISINFECTION: Type Amt. Used <br /> 12 WELL TEST DATA: ❑Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test. <br /> TESTING METHOD <br /> Static Level ft. DatefTime measured , Production Rate gpm. <br /> Pumping level ft. Date/Time measured , Test length (hrs.) <br /> Remarks <br /> 3 ,ve read the statements made herein and know the contents thereof,and that they are true to my knowledge. [Pursuant to Section 24-4-104(13)(a) <br /> S.,the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.] <br /> ,4TRACTOR Phone (_, Lic. No. <br /> Mailing Address <br /> Name/Title (Please type or print) Signature Date <br />