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FORM NO. <br />GVYS -31 <br />0412005 <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman SL, Room 818, Denver, CO 80203 <br />Phone — Info (303) 866 -3587 Main (303) 866 -3581 <br />Fax 886 -3589 httP:#wwwwater.sta1a.co.us <br />For Office Use Only <br />RECEIVE', <br />01� <br />V MITER RESOURCES <br />STWk <br />��NEFR <br />1. WELL PERMIT NUMBER: Z $S 8 <br />2. WELL OWNER WFORMATION <br />NAME OF WELL OWNER: S i IS <br />MAILING ADDRESS: 6,29 <br />CITY. NU d STATE: 0 ZIP CODE: 1 <br />TELEPHONE NUMBER: 0 b - 2 / <br />3. WELL LOCATION AS DRILLED: N W 114, X114, Sec. IS', Twp. IV7 11 N or ❑ S, Range /& ❑ E or ® W <br />DISTANCES FROM SEC. LINES: 7 o It from IQ N or ❑ S section line and 6 Y S ft from ❑ E or Pg 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 w� , Fasting: <br />must be meters, Datum must be NA083, Unit must be set to true N, ❑ Zone 12 or [I Zone 13 <br />STREET ADDRESS AT WELL LOCATION: R 600 Nueld L 0 61 Y.Z Northing: <br />4. GROUND SURFACE ELEVATION ' 717 feet DRILLING METHOD o - 141 ' <br />DATE COMPLETED 10///" TOTAL DEPTH 35- feet DEPTH COMPLE ED d S feet <br />S. GEOLOGIC LOG: <br />6. HOLE DIAM in. From ft To ft <br />Depth <br />Tvpe <br />Grain Size <br />Color <br />Water Loa <br />- <br />0-10 <br />s <br />F.• <br />/2e <br />�— <br />I <br />'- <br />A -owrl <br />J <br />Z <br />--- <br />(fi--ev <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />_ .5ell %z o <br />PERFORATED CASING: Screen Slot Size (in):O <br />8. FILTER PACK: <br />Material <br />size <br />Interval <br />8. PACKER PLACEMENT: <br />Type srrfi FA•�pJg, PeeAn-- <br />.Z 3 <br />D th <br />0. GROUTING RECORD <br />Material Amount Density In+ —al Placement <br />;#' !WL 13-2.1 <br />Remarks: <br />11. DISINFECTION: T Amt Used <br />12. WELL TEST DATA LJ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test <br />TESTING METHOD <br />Static Level ft. Date/Time measured: Production Rate gpm. <br />Pumping Level ft. DaWTime measured Test length (hrs) <br />Remarks: #,0 well PCpq gen&rMild <br />13. 1 have read the statements mbde herein and know the contents thereof, and they are true to my knowledge. This document is signed and certified in <br />accordance wflh Rule 17A 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 -1 1 e C.R.S., and Is punishable by fines up to $5000 and/or revocation of the conlracting fioense. <br />Company Name: <br />WCsf �7 fz-fels 9 /orA o <br />Phone: <br />0 6 <br />License Number: <br />Maili Address: 1 6,9-0 Cn <br />Signatu : <br />Awf 4 <br />PHI t Name and Title _ <br />,� Lw7 " (9Po10 , r <br />Date <br />#/Y/// <br />