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FORM NO. ' <br />GYYS-31 <br />0412005 <br />• <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 — Into (303) 866.3587 Main (303) 8883581 <br />Fax 03 886 -3589 htt :! /www.water_state.co.us <br />For Office Use Only <br />APR 15 2011 <br />MYITER RESOURp & <br />STA <br />TE I� <br />dOt� NEF <br />1. WELL PERMIT NUMBER: 9Jr I O <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: We fie/ cr lS 60104ado <br />MAILING ADDRESS: AQ 80A 619 <br />CITY: l4 STATE: CO ZIP CODE: 914 <br />TELEPHONE NUMBER: ff 70 - 2-1 tv <br />3. WELL LOCATION AS DRILLED: ,�— 114, *W114, Sea 2,S-- Twp. 47 ' ® N or ❑ S, Range 16 ❑ E or ® W <br />DISTANCES FROM SEC. LINES: 1777 R from 96 N or ❑ S section line and 2.553 ft. from ❑ E or [M 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 Designabon:ae 1 <br />must be meters, Datum must be NAD83, Unit must be set to true N, ❑ Zone 12 or ❑ Zone 13 Easbng: <br />STREET ADDRESS AT WELL LOCATION: )— 6 $0 ad s 4414 C O I yz f Northing: <br />4. GROUND SURFACE ELEVATION 5? E 7 feet DRILLING METHOD it <br />DATE COMPLETED 10/1 /OS TOTAL DEPTH feet DEPTH COMPLETED 3 feet <br />S. GEOLOGIC LOG: <br />S. HOLE DIAM in. From ft To ft <br />Depth I <br />T e <br />Grain Size <br />Color <br />Water Loc. <br />_ G - �Iy O <br />60 01 <br />— <br />1,9C.4 <br />36- 18 <br />6re* <br />36'9 <br />7. PLAIN CASING: <br />OD (in) QK�in�d� Wall Size (in) From (ft) To (ft) <br />g DG I I b y n 'o <br />PERFORATED CASING: Screen Slot Size (in):D•A!1 <br />_ 219 39 <br />8. FILTER PACK: <br />Material <br />Size <br />Interval <br />9. PACKER PLACEMENT: <br />Type A2& fty1"0,a7 p0r*e- <br />'26 <br />Depth <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />&Iwif ee IT 1 2 b <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 R DateIrme measured: Production Rate gpm. <br />Pumping Level fL Date/rime measured Test Length (hrs) <br />Remarks: S <br />1S. 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 />Is co tor' <br />Phone: <br />& - 2146 <br />License Number. <br />Mallin Address: Po B &.28 ,i' ,,tr�r y6j D flqll <br />Signature- <br />Print Name and Title <br />- bee ! <br />to <br />