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FORM NO. <br />GWS -31 <br />0412005 <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St, Room 818, Denver, CO 80203 <br />Phone - Info (303) 666 -3587 Main (303) 866 -3581 <br />Fax 303 866 -3589 htt :Hwww.water.state.co.us <br />For Office Use Only <br />APR 15 2011 <br />WATER <br />A��INEEEER S <br />1. WELL PERMIT NUMBER: 2,95-8,1S, <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: Wqrern ke.15 vloradO <br />MAILING ADDRESS: P 0 <br />CITY: MIC101 STATE: G 0 ZIP CODE: y <br />TELEPHONE NUMBER: l <br />3. WELL LOCATION AS DRILLED: At;j�114, jdy 914, Sec 2Lf Twp. !% CK N or ❑ S, Range-Kt- ❑ E or 1YW <br />DISTANCES FROM SEC. LINES: I i9 ft. from [X N or ❑ S section line and (d6 'Q ft- from ❑ E or [O W section line. <br />SUBDIVISION: , LOT , BLOCK , FILING (UNIT) <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owners Well Designation: 6W-# <br />must be meters, Datum must be NAD83, Unit must be set to true N, ❑ Zone 12 or ❑ Zone 13 Easting- <br />STREET ADDRESS AT WELL LOCATION: 2 d /Yri D S I fil ft Northing: <br />4. GROUND SURFACE ELEVATION � 1-7 feet DRILLING METHOD 1>!! -Air <br />DATE COMPLETED J01t10j TOTAL DEPTH (4 b feet DEPTH COMPLETED 4 19 feet <br />6. GEOLOGIC LOG: <br />6. HOLE DIAM in. From ft To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Lac. <br />/0 -PY 11 t7 l <br />— <br />S <br />F;n <br />r <br />r- <br />8r <br />% e, <br />A, r C4 <br />301- <br />7. PLAIN CASING: <br />OD (in) Kind W�all Size ,(in) From (ft) To (ft) al <br />PERFORATED CASING: Screen Slot Size (In): <br />itt bell &h Iel <br />- <br />?oaf <br />— <br />saves <br />R' <br />r <br />S — <br />8. FILTER PACK: <br />Material <br />Size <br />Interval <br />S. PACKER PLACEMENT: <br />Type So# &-gmo7 Pilllk <br />4$ <br />Depth <br />0. GROUTING RECORD <br />Material Amount D nsity Interval Placement <br />&Rani G logo] -Z01/44" -1 <br />Remarks: <br />11. DISINFECTION: Type I Amt. Used <br />12. WELL TEST DATA: Ll Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level ft. Daterrime measured: Production Rate gpm. <br />Pumping Level ft. Daterrime measured Test Length (hrs) <br />Remarks: <br />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 <br />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 <br />section 37 -91 -108 1 e , C.R.S. and is punishable by fines up to $5000 and/or revocation of the contracting license. <br />Company Name: <br />f /S <br />Phone: <br />License Number: <br />Mailina Address: /° <br />Signatu <br />13714ame and Title - GeOr <br />e <br />