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2014-05-12_PERMIT FILE - C2010089 (8)
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2014-05-12_PERMIT FILE - C2010089 (8)
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Last modified
8/8/2017 10:11:18 AM
Creation date
8/8/2017 10:09:17 AM
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Template:
DRMS Permit Index
Permit No
C2010089
IBM Index Class Name
Permit File
Doc Date
5/12/2014
Doc Name
Approved Well Permits
Section_Exhibit Name
Appendix 2.05.6(3)-4
Media Type
D
Archive
No
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FORM No. <br />GWS-31 <br />04!2005 <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) 866 -3581 <br />Fax 8863589 h :Nwww.wster.stete.co,us <br />For Office Use Only <br />�t� %EI_ <br />APR g 5 2Qi� <br />HATER RESOUHCES <br />SAT ENQIUEFA <br />1. WELL PERMIT NUMBER: <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: e0er,? E" eh 1"Olnl-ddo <br />MAILING ADDRESS: PO Ogg 6,20 <br />CITY: u / STATE: CO ZIP CODE: 1 .2 <br />TELEPHONE NUMBER: 1770 Gif - ,2I <br />3. WELL LOCATION AS DRILLED: 5.6 114, &114, Sec. j5_, Twp. 14 7 $j Nor [IS, Range ❑ E or$J W <br />DISTANCES FROM SEC. LINES. f ? SQL ft. from ® N or ❑ S section line and ZCL SG R from ❑ E or ® 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: L- W2- <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: —7,?Af, Nziz le G o ql Northing: <br />4. GROUND SURFACE FLEvAT10N g53 I feet DRILLING METHOD Iii <br />DATE COMPLETED /0--'2/08 TOTAL DEPTH 2. feet DEPTH COMPLETED 2 feet <br />5. GEOLOGIC LOG: <br />6. HOLE DIAM in. From R To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />�o'3 /y CJ of <br />! <br />- <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />B l/ a##o__ <br />PERFORATED CASING: Screen Slot Size (in): 0- 012 <br />8. FILTER PACK: <br />Material <br />Sae <br />Interval <br />9. PACKER PLACEMENT: <br />Type +on Pokff <br />3 <br />DeM <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />&QrW10 to 661 2,b*w^ '3— 11 <br />&WA-, e, ls�at <br />Remarks: <br />11. DISINFECTION: I Amt. Used <br />12. WELL TEST DATA: 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: /V /1 reir Mr P ri�71e <br />13. 1 have read the sUlernents mdde hereln and know the contents thereof, and they 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 Ming of a document that contains false statements Is a violation of <br />section 37 -91 -1 1 e C.R.S. and Is pmlshable by fines up to $5000 andfor revocation of the conbracUng license. <br />Company Name: <br />w r•, Aels Go/ora <br />Phone: <br />70 y -2165 <br />License Number <br />Mailing Address: P Y, 1 q2 <br />Signatu <br />7L.4 A.& <br />P - t Name and Title <br />, Aw,,d G�ola . " <br />Date <br />4/0'/11 <br />
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