Laserfiche WebLink
FORM NO. <br />GWS-31 <br />0412005] <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />13P� hean n St, Room 818, Denver, CO 60203 <br />(303) a06 -3587 Main (303) SM -3581 <br />Fax 303 886 -3589 :lhwvw.water.state.co.us <br />For Office Use Only <br />RE,,f,,El\.1�(, <br />APR 15 2011 <br />WATER RESOURCES <br />STATIEC�l1C�tNEEa <br />� <br />1. WELL PERMIT NUMBER: 2 « i06 <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: A1191S 6 r <br />MAILING ADDRESS: <br />CITY: /Vat STATE: 0 ZIP CODE: yaAl <br />TELEPHONE NUMBER: 7 <br />3. WELL LOCATION AS DRILLED: 114, NW 114, Sec.ftffTwp. N or ❑ S, Range 1% ❑ E or Ow <br />DISTANCES FROM SEC. LINES: 71) ft from Q N or ❑ S section line and 655 ft from ❑ E or NJ 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 Owner's Well Designation: > •Hy8 <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: Zqd&d 16 00 co Northing: <br />4. GROUND SURFACE ELEVATION S 7 I -7 feet DRILLING METHOD - <br />DATE COMPLETED Q TOTAL DEPTH 7 feet DEPTH COMPZ TED 7 feet <br />8. GEOLOGIC LOG: <br />6. HOLE DIAM in. From ft To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />(g - Z/I 51' 7 <br />50 o <br />i <br />r <br />- .20 <br />SIVAS <br />_ <br />re l✓ <br />20-35- <br />"' <br />6/e 4 <br />?0-0 <br />7. PLAIN CASING: <br />OD (in) Kind [W��alll�l Size (in) From (ft) To (ft) <br />BGT +4�.r/ 7 [� 7 <br />PERFORATED CASING: Screen Slot Size (in): R OZ <br />- <br />If <br />&t2th <br />15--49' <br />r <br />t <br />8. FILTER PACK: <br />Material <br />Size <br />Interval <br />8. PACKER PLACEMENT: <br />Type J.& r &WVA�,7 Par,(tl9r' <br />35- <br />Depth <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />BqjbjiAe jQggl .? ]mots 51-7-37 <br />.5-27 <br />Remarks: <br />11. DISINFECTION: T e Amt Used <br />12. WELL TEST DATA: U Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test <br />TESTING METHOD <br />Static Level R DatefTime measured: Production Rate gpm. <br />Pumping Level ft Date/Time measured Test Length (hrs) <br />Remarks: <br />11 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 -1080)(e), C.R.S., and is punishable by fines up to $5000 and /or revocation of the contracting license. <br />Company Name: <br />Wesy&4 F ! <br />Phone: <br />17e 6 <br />License Number. <br />Mailing Address: PO 80A 626 Nudix L <br />Signature: <br />Pn Name and Title <br />an -- G olo ✓'sr- <br />D a e <br />.7/ <br />