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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) 866-3587 Main (303) 888 -3581 <br />Fax 303 W6 -3589 Jhvww.water.stata.co.us <br />For Office Use Only <br />S Ak^ aw <br />1. WELL PERMIT NUMBER: 21?.5 SI <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: q G I rll <br />MAILING ADDRESS: PC **Y 6 SL$ <br />CITY: //Madt STATE: ZIP CODE: I z <br />TELEPHONE NUMBER: - rZ16 <br />3. WELL LOCATION DRILLED: S E 114, JV W 114, Sec. *1-5-. Twp. '17 N or ❑ S, Range E or ® W <br />DISTANCES FROM SEC. LINES: 7'1 Y ft. from ® Nor ❑ S section line and 2 is 55' ft. from ❑ E or [N 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: I, JW-01TO <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: Z ZR 9 Mc LD 9/ya 9/y Northing: <br />4. GROUND SURFACE ELEVATION 57�3 feet DRILLING METHOD it <br />DATE COMPLETED /0 TOTAL DEPTH Ll a feet DEPTH COMPLETED Beet <br />5. GEOLOGIC LOG: <br />6. HOLE DIAM in_ From ft To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />III - 5 <br />Ss1'e <br />2 a-12r <br />.Z <br />10t <br />5`-3 r <br />MOO, <br />GI' <br />- 8 <br />7. PLAIN CASING: <br />OD (in) pKiin�d� Wall Size (in) From (ft) To (ft) <br />PERFORATED CASING: 1 � Slat Size <br />k110 39 9 <br />8. FILTER PACK: <br />Material <br />Size <br />Interval <br />9. PACKER PLACEMENT: <br />Type sod foi rrli M Pdc&6 <br />36 <br />Depth <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />_ e& _If 0-76 <br />Remarks: <br />11. DISINFECTION: T Amt Used <br />12. WELL TEST DATA: El 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. Daterrime measured Test Length (hrs) <br />Remarks: Ao weil &,-fAr ent,, udl <br />13. I have read the staternerrts madd herein and know the contents thereof, and It" are true to my knowledge. This document is signed and certified In <br />accordance with Rule 17A of the Water Well Construction Rules, 2 CCR 402 -2. [The Illing of a docurnent that contains false statements is a violation of <br />section 37 -91 -1 1 e C.R.S. and is punishable kry fines up to $5000 and/or revocation of ft contracbrig license, <br />Company Name: <br />weite. -r, F14 lS CO a d-O <br />Pbone, <br />16Q - ;- 143 <br />License Number. <br />Mailing Address: P10 v 0( 12 11144610 60 L% <br />Signature: <br />4 , <br />Print Name and Title <br />012 L rr dt? - eo[e : sr <br />Dat <br />/i /l <br />