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FORM NO. <br />G'W&31 <br />041M <br />• <br />' WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman SL, Room 818, Deaver, CO 80203 <br />Phone — Info (303) 866 -3587 Main (303) 868 -3581 <br />Fax 303 866 -3589 hRV:/Avww.wa1er.state.ca.us <br />For Office Use Only <br />APR 1 5 2011 <br />AATEKKESOURCES <br />STA NEER <br />1. WELL PERMIT NUMBER: Z85 -*2'0 <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: I/I/L V&- FL-ejl COJ <br />MAILING ADDRESS: P4 BOA (o <br />CITY: fteia STATE: 60 ZIP CODE: <br />TELEPHONE NUMBER: 70 fs -:2/415' <br />3. WELL LOCATION AS DRILLED: 5W 114, -V JV 1/4 . Sec. , Twp. N or ❑ S, Range LA__ ❑ E or ® W <br />DISTANCES FROM SEC. LINES: qf__.�Z— ft. from ❑ N or ® S section line and 4 / ft from ❑ E or lJ W section line. <br />SUBDMSION: —,LOT— BLOCK , FILING (UNIT) <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTIM, Units Ownees Well Designation:�� <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: ;,(00AWAAAd. Nitc/ Q Northing: <br />4. GROUND SURFACE ELEVATION 37#10 feet DRILLING METHOD Aotweg 4;,- <br />DATE COMPLETED 7/3 O OR TOTAL DEPTH /O feet DEPTH COMPLETED X10 feet <br />S. GEOLOGIC LOG: G. HOLE DIAM in. From ft To ft <br />De th <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />_2 <br />r <br />849 W4 <br />- <br />>r <br />_ <br />5- 1-0 <br />T <br />r <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) Tn 1111 <br />_ Belt SGH Yo e? l00 <br />PERFORATED CASING: Screen Slot Size (in): Q. <br />K P11 56" 100 /10 <br />f- <br />`' <br />— <br />Jac <br />`- <br />a4g— lop <br />/ <br />8. FILTER PACK <br />Material <br />Size <br />Interval <br />S. PACKER PLACEMENT: <br />Type �O& FP -14*49 It$ItkPr <br />100 <br />Depth <br />D. GROUTING RECORD <br />Material Amount Density Interval Placement <br />Vii& /a P! 90-/022 <br />Remarks: <br />11. DISINFECTION: Type 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. Date/Time measured: Production Rate gpm. <br />Pumping Level ft DateMme measured Test Length (hrs) <br />Remarks: o- rf <br />13. I 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 flung of a document that contains false statements Is a violation of <br />section 37-91 -106 1 e G.R.S., and Is punishable by Braes Lip to $5000 and /or revocation of the contracts license. <br />Company Name: Phone: <br />r L41 r' 6 64 - vw(f <br />License Number: <br />Mailin Address: PD 8ft 6.Z /V O 1µ2 7 <br />Signature: Print Name and Title <br />- Geo1 "sr <br />Date <br />