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FORM No. <br />GWS-31 <br />04rM <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 — Info (303) 866.3587 Main (303) 868-3581 <br />Fax 303 886.3589 hftpJhvww.waIer.state.co.us <br />For Office Use Only <br />RECEIVEF <br />APR 15 2011 <br />,' <br />;yR(ES <br />tNATER RESi.STATE , E�NQINRk <br />1. WELL PERMIT NUMBER: 2. f S 8 2.f <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: S F d <br />MAILING ADDRESS: PO &k 162-y <br />CITY: Afarlit STATE: C O ZIP CODE: <br />TELEPHONE NUMBER: <br />3. WELL LOCATION AS DR&LED: XW 114, - I-E�114, Sec -2_*_ Twp. Y 7 ® N or ❑ S, Range L6L_ ❑ E or 4 W <br />DISTANCES FROM SEC, LINES: 1 q7 Sl ft from ❑ N or to S section line and !�t I ft. from ❑ E or R 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 Designationb M� <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: 2600 4, �Q Northing: <br />4. GROUND SURFACE ELEVATION ° ]Meet DRIWNGMETHOD /' , <br />DATE COMPLETED JIM109 TOTAL DEPTH feet DEPTH COMPLET feet <br />5. GEOLOGIC LOG: <br />5. HOLE DIAM in. From ft To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loa <br />/o - �/4 9(ice <br />-2n <br />- <br />r <br />45%7-7o9 <br />Qwle <br />-- <br />f <br />' <br />7. PLAIN CASING: <br />OD (in) Kind Wail Size (in) Frnm (ft) To (ft) <br />_Ll 76 <br />PERFORATED CASING: Screen Slot Size (in): D O� <br />s 90 <br />- 5hpl, <br />irtmol <br />8. FILTER PACK <br />Material <br />Size <br />Interval <br />9. PACKER PLACEMENT: <br />Type SQL g POI�o' <br />to <br />Depth <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />%Q,l 5( <br />S-Gg <br />Remarks: <br />11. DISINFECTION: Tye 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 IL Daterrime measured Test Length (hra) <br />Remarks: Alota Well &r& fff2n�df <br />13. I have read ft statements made herein and know the contents thereof, and they are true to my knowledge. This document Is signed and certified in <br />acc mdance 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 pun1whable, by firms up to $5000 and /or revocation of the contracting license. <br />Company Name: Phone: <br />Wevern Fitels G l ra 9V 90y -21 <br />License Number. <br />Mailing Address: 6 NUCIA 60 / 2 9 <br />Signature: Print a and Title <br />S L imde - <br />Date <br />