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FOA <br />cwsa1° <br />WELL CONSTRUCTION AND TEST REPORT <br />10'9a <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />For Office Use only <br />1313 Sherman St_, RM 818, Denver, CO 80203 <br />1:ZZIMV�D <br />t. <br />WELL PERMIT NUMBER MH-43400 <br />APR $ $ 2004 <br />2. <br />OWNER NAME(S) Silver Peaks Meir Witan District No.1 <br />Mailing Address 54§9 South Quebec StrW. SNilg110 <br />C,-;C, <br />6TAT r <br />City, Sl. Zip Greenwood Village. CO 80111 <br />. <br />COLO. <br />Phone(303) 773-1005 <br />3. <br />,WELL LOCATION AS DRILLED: M 114 NE _114, Sec. 35 Twp_ 1 S _, Range _ 67 _ W <br />DISTANCES FROM SEC. LINES: <br />2 0 5 0 ft. from N Sec. line. and 700 ft, from E Sec. line. OR <br />wwQSUBDIVISION: LOT _ _B OCK FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: NIA <br />4. <br />GROUND SURFACE ELEVATION 5030 ft. DRILLING METHOD 4114' HSA _ <br />DATE COMPLETED 4114/04 _TOTAL DEPTH eft. DEPTH COMPLETED _ 33 ft. <br />6. HOLE DIAM. (in.) From (ft) To (ft) <br />5. GEOLOGIC LOG= <br />8 0 35 <br />Depth DaNdpeon of Material (Type, Size. Calor, water Location) <br />0 — 8.5' Clayey sand, fine to medium grained sand, <br />7. PLAIN CASING <br />OD (In) Kind Wall Slze From(ft) To(ft) <br />2 PVC SCH 40 3' AGS _Z3_:_. <br />PERF_ CASING. Screen Slot Size: 0.01" <br />2 PVC SCH 44- 23, 3Y <br />-- <br />Slightly moist-moist, brown-dark brown to <br />Orange-brown, loose. <br />8.5'— 13' Sand, poorly graded, some coarse sand, <br />Some 1" gravel, slightly moist-moist, <br />Light brown -brown. <br />13' —16' Clayey sand, fine to medium sand, moist-wet, <br />Brown to orange-brown, loose, slightly lastic. <br />33' Gravel!y sand to sandy gravel <br />8. FILTER PACK: <br />Material Sand <br />Size, 10-20 <br />Interval 5'— 16' <br />9. PACKER PLACEMENT: <br />Type <br />D th <br />_16'— <br />35' Sandy cls lone, fine grained sand, <br />_33'— <br />Slightly moist, brown-yellow, orange staining, <br />Dense. <br />10. GROUTING RECORD: <br />Material Amount Density Interval Placement <br />Cotkrete t baO 0-11 <br />1.5 baas 1�5, <br />REMARKS: MW-20UT <br />Water Level = 22' <br />Natural Cave =16' — 35' <br />11. <br />DISINFECTION: Type Amt. Used <br />12. <br />WILL TEST DATA Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level ft. Dale/Time measured , Production Rate gpm. <br />Pumping level H. DatelTlme measured , Test length (hrs.) <br />Remarks <br />13. i have read the statements made herein and know the contents thereof. and that they are true to my knowledge. ;Pursuant to SWbn 24-4-104(13) lel <br />C.R.S.. the making of [also statementa herein cona2was perjury In the secon degree and b ptmlehable as a class 1 misdemearhor.) <br />CONTRACTOR Tetra Tech RMC Phone ( 303 1 772-5282 Lic. No. <br />Mailing Address 1900 South Sunset Street, Suite 1-F, Longmont, Colorado 80501 <br />amaMlle (Please type or print) <br />ignature <br />Date <br />Marshall Massaro, Scientist <br />r,w505Oe2%Well Construction Rgwns1.%1 W20Ur.dw <br />