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FORM NO. WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br />GWS-31 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />0412005 1313 Sherman St, Room 818, Denver, CO 80203 <br />RE-CE V /n <br />Phone — Info (303) 888-3587 Main (303) 888 -3581 E . <br />Fax 303 8611-3589 :11www.waW.stale.co.us <br />1. WELL PERMIT NUMBER: &IrY 1'23 <br />2. WELL OWNER INFORMATION APR 15 2011 <br />NAME OF WELL OWNER: (,/es F IS Colol-ody WATER R�k'Sl,vhi 't <br />MAILING ADDRESS: P o STATE EN IMF r+ <br />CITY: /Y STATE: ZIP CODE: AW it <br />TELEPHONE NUMBER: - <br />ec. 2 S Twp. --q-Z ® N or ❑ S, Range /to ❑ E or ® W <br />3. WELL LOCATION AS DRILLED: W114, x_1/4, Sec.-25' <br />DISTANCES FROM SEC. LINES: f 1 A 6 ft. from ❑Nor ®S section line and -41 - -_ ft. from ❑ E or N W section line. <br />SUBDIVISION: LOT , BLOCK . FILING (UNIT) <br />Owner's Well Designation:6W <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units <br />Easting: <br />must be meters, Datum must be NAD83, Unit must be set to true N, ❑ Zone 12 or ❑ Zone 13 <br />STREET ADDRESS AT WELL LOCATION: 26jQjQ gad Northing- <br />4. GROUND SURFACE ELEVATION C%2 O _ feet DRILLING METHOD o - A•� <br />DATE COMPLETED 11YO109 TOTAL DEPTH feet DEPTH COMPLETED feet <br />5. GEOLOGIC LOG: <br />S. HOLE DIAM in. From ft To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />0-.10- <br />Shale <br />- <br />o- <br />(i <br />— <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />. Alea Sep qt? _0 6 <br />PERFORATED CASING: Screen Slot Size (in): &92 <br />wig <br />8. FILTER PACK <br />Material <br />Size <br />Interval <br />9. PACKER PLACEMENT: <br />Type Safi-Fmu�tien PatkPt <br />S <br />Dept <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />_7 fim,&S. MS'S <br />Remarks: <br />11. DISINFECTION: Type 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 ft. Datelrime measured: Production Rate gpm. <br />Pumping Level ft. DatelTime measured Test Length (hrs) <br />Remarks: No W 1l Y rAe- <br />13. 1 have read the statements ryfade herein and know the contents thereof, and they are We to my knowledge. This document Is signed and certified in <br />accordance with Rule 17.4 of the Water Weli Consbuc ian Rutes, 2 CCR 402 -2. (The filing of a document that contains false statements is a violation of <br />section 37-911-108(1)(e). C.R.S., and Is punishable by fines up to $5000 aridlor revocation of the contracdnq license. <br />Company Name: <br />Phone: <br />License Number <br />sternp �! f <br />4�7v W64 b <br />Mailing Address: Po Co 2 <br />rwature : Print Name and r�d� _ <br />Date, <br />GeO/ �S>~ <br />/ <br />