2017-02-24_PERMIT FILE - M1986140

• Permit No: M1986140
• IBM Index Class Name: Permit File
• Doc Date: 2/24/2017
• Doc Name: Adequacy Review Response
• From: Park County Public Works Department
• To: DRMS
• Email Name: MAC
• Media Type: D
• Archive: No

FORM Na. WELL.CONSTRUCTION AND TEST REPORT For Office Use Only
GWS-31 STATE OF COLORADO,OFFICE OF THE STATE ENGINEER
04/2005 1313 Sherman St.,Room 618,Denver,CO 80203
Phone—Info(303)866-3587 Main(303)866-3581,'
Fax [phone] -1 http://www.water.state.ca.us
11. WELL PERMIT NUMBER:27288t— RECEIVED
2. WELL OWNER INFORMATI N
NAME OF WELL OWNER: Larry Plote
MAILING ADDRESS: 15330 East Via Del Ranch WATEgp,-^UICEs
CITY: Chandler STATE:AZ. ZIP CODE: 85249 STATE- �kEER
TELEPHONE NUMBER: 602 757-1727 coo.
3. WELL LOCATION AS DRILLED: NW1/4, SE1/4, Sec. 14, Twp. 8 ❑N or®S, Range 76 ❑E or®W
DISTANCES FROM SEC.LINES: 1966 ft.from ❑N or®S section line and 1966 ft.from ® E or❑W section line.
SUBDIVISION: LOT BLOCK , FILING(UNIT)
Optional GPS Location:GPS Unit must use the following settings: Format must be UTM, Units Owner s Well Designation-.
must be meters, Datum must be NAD83, Unit must be set to true N, ❑Zone 12 or®Zone 13 Easting:426537
STREET ADDRESS AT WELL LOCATION: Northing:4356338
4. GROUND SURFACE ELEVATION Unknown feet DRILLING METHOD Air
i
DATE COMPLETED 6-24-07 TOTAL DEPTH 217 feet DEPTH COMPLETED 217 feet
5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth': T e Grain Size Color Water Loc. 9 0 62
0-54 Gravel,sand Boulders 61/4 62 217
54-67 Clay Gray
67-119I Shale Gray 7. PLAIN CASING:
119-131 Sandstone OD(in) Kind Wall Size(in) From(ft) To(ft)
131-181 Shale Grav 1 7 Steel .215 +1 62
181-192 Sandstone KX 4.5 P.V.C. 214 -10 117
192-217 Sandstone Sh le 4.5 P.V.C. .214 137 177
PERFORATED CASING: Screen Slot Size(in):.032
4.5 P.V.C. .214 117 137
4.5 P.V.C. .214 177 217
8. FILTER PACK: 9. PACKER PLACEMENT:
Material Type Rubber
Size
Interval Depth 80 ft.
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: Cement 9.5cuft 15# 11-51 Vibrated
11. DISINFECTION: TyRe H.T.H. Amt.Used 6 Oz.
12. WELL TEST DATA: LJ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD Air .
Static Level+/-50 ft. Date/Time measured`.6-24-07 Production Rate.+/-70 gpm.
Pumping Level 207 ft. Date/Time measured 6-24-07 Test Length(hrs)1
Remarks:
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
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
section 37-91-108 1 e,C.R.S.,and is punishable by fines up to$5000 and/or revocation of the contracting license.
Company Name: 1�1 Phone: License Number:
James Dn"lling Company L81 343
Mailing Address:6235 West 5e enue, Arvada Co!80002
Signature: Print Name and Title Date
g Michael Keaton,President 7/26/2007