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5 � <br /> FO M No. WELL CONSTRUCTION AND TEST REPORT a Use only <br /> ivs4 t RE��('p STATE OF COLORADO, OFFICE OF THE STATE ENGINEER � <br /> 1. WELL PERMIT NUMBER 255224 APR 16 2004 <br /> 2 OWNER NAME(S) John Tietz WArERREsouacES <br /> Mailing Address 16640 Yampa Way STATE ENGINEER <br /> City, St. Zip Brighton, Co. 80601 p 360 <br /> Phone (303 ) 659-2420 1 <br /> 3 WELL LOCATION AS DRILLED: SW 1/4 NE 1/4, Sec, 14 Twp. 8 S Range 76 W <br /> DISTANCES FROM SEC. LINES: <br /> 2400 ft. from North Sec. line. and 2 4 5 7 ft. from�� Sec. line. OR <br /> (no?TM or south)SUBDIVISION: LOT BLOCK FILING(UNIT) <br /> STREET ADDRESS AT WELL LOCATION: House well <br /> 4. GROUND SURFACE ELEVATION Unknwofh DRILLING METHOD A; r <br /> DATE COMPLETED 4-5-04 TOTAL DEPTH 201 ft. DEPTH COMPLETED 201 ft. <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM. (in.) From (ft) To (ft) <br /> Depth Description of Material (Type,Size, Color,water Location) 9 0 4 8 <br /> 0 2 T6psoil 6 1 /8 48 201 <br /> :2 38 Sand & gravel xx <br /> 38 71 Sandy clay, medium <br /> 71 1 1 3 Shale ( silty) xx 7. PLAIN CASING <br /> 1 1 3 201 Shale, gray OD (in) Kind Wall Size From(ft) To(ft) <br /> 7 Steel .219 +1 79 <br /> 4 1;' Py v.r,. 214 -ate <br /> PERF. CASING: Screen Slot Size: . 032 <br /> 4.5 P.V.C. .214 - 101 201 <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material Type Rubber _ <br /> Size <br /> [ntervai Depth 81 f t. <br /> 10. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br /> REMARKS: Cement 5cuft. 15 <br /> 1 DISINFECTION: Type H. T.H. Amt. Used 6 Oz. <br /> WELL TEST DATA: ❑Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test. <br /> TESTING METHOD Air <br /> Static Level ± 20 ft. Date/Time measured 4-5-0 4 _ Production Rate 10 gpm- <br /> Pumping level _ft. Date/Time measured 4-5-04 , Test length (hrs.) 1 <br /> Remarks <br /> 3. 1 have 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 /> C.R.S.,the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.} <br /> CONTRACTOR James Drilling Company Phone C 303 420-51 81 Lic. No. 1134 <br /> Malin Address <br /> Name/Title (Please type or print) Signature Date <br /> Michael Keaton, President 4-14-04 <br />