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WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For Office Use Only <br /> Form No. State of Colorado, Office of the State Engineer <br /> GWS-31 1313 Sherman St., Room 821, Denver, CO 80203 303.866 3581 <br /> 02/2017 www.water.state.co.us and dwrnermitsonhnec,�;state cu-us <br /> 1.Well Permit Number: 5fjg�17 Wlt Receipt Number: <br /> 2.Owner's Wet Designation:LTC-GW-2 0 , <br /> 3.Well Owner Name:Transit Mix Concr ete Co. <br /> 4.Well Location Street Address:2485 Hitch Rack Ranch Road, Colorado Springs, CO 80926 <br /> 5.As Built GPS Well Location(required): []Zone 12 []Zone 13 Easting:509856.0 Northing:4278527 <br /> 6.Legal Well Location: NW 114, SE 1 i a, Sec , 16 Twp. 16 N or S 0 Range 67 E or W 5 P.M. <br /> County: El Paso m <br /> Subdivision: Lot— Block— , Filing(Unit) <br /> 7.Ground Surface Elevation:6,799 feet Date Completed: 07/18/2017 Drilling Method: Air Hammer <br /> 8.Completed Aquifer Name: Granite Total Depth: 103 feet Depth Completed: 103 feet <br /> 9.Advance Notification: Was Notification Required Prior to Construction? F1 Yes No, Date Notification Given: 06/1612017 <br /> 10.Aquifer Type: Type I (One Confining Layer) aype I (Multiple Confining Layers) []Laramie-Fox Hilts <br /> (Check one) ❑Type If (Not overtain by Type III) QType 0 (Overlain by Type 111) ❑Type III (alluvialcolluvial) <br /> 11. Geologic Log: 12. Hole Diameter(in.) Frem (ft) To ift) <br /> Depth Type Grain Size Color Water Loc. 6 5;8 0 19 <br /> 0 Alluvium Sandy Gravel Light Brown 13 4 13/16 19 103 <br /> 7 Granite NA Red 13 <br /> 13.Plain Casing <br /> OD(in) Kind Wait Size Om Fr Din (ft) TO(ft) <br /> See Attached Sheet <br /> Perforated Casing Screen Slot Size tin): 3/8 _ <br /> OD(in) Kind Wall Size on) FrDin (ft) To tft) <br /> See Attached Sheet <br /> 14. Filter Pack: 15. Packer Placement: <br /> Material Sand Type NA <br /> Size 12 20 NA <br /> Interval See Attached Depth <br /> 16. Grouting Record <br /> Material Amount Density Interval Method <br /> Remarks: Grout 32 Gat See Attached <br /> 17. Disinfection: Type NA Amt. Used NA <br /> 18.Well Yield Estimate Data: DiCheck box if Test Data is submitted on Form Number GWS 39, Well Yield Test Report <br /> Well Yield Estimate Method: Peristaltic Pump and Air Pump <br /> Static Level: See Attached Sheet Estimated Yield (gpm) SeeAttached <br /> Date/Time measured:- Sept. 2', 2017, 2:05 PM Estimate Length(hrs) 8 _____,_ <br /> Remarks:See Attached Sheet for well completion information. <br /> 19. 1 have read the statements made herein and know the contents thereof and they are true to aiy knowledge This document is signed(or name entered r <br /> filing online)and certified in accordance with Rule 17 4 of the Water Well Construction R,,'.es, 2 CCR 02 2 The filing of a document that cor,ta,ns'alse <br /> statements is a violation of section 37 91 108(1 He), C R 5 ,and is punishable by fires up to Si 000 and o revocation of the cc,,tracting license if`ding online <br /> the State Engineer constoers the ent•y of the licensed rontract_,r z name to be compliance.sith Ru,e 17 4 <br /> Company Name: Email Phone wiarea code: License Number: <br /> Authentic Drilling MarcC-Autnenticd rill ing.corn (720)465-1450 1510. i I <br /> Mailing Address:201 Perry Park Ave. P105 Larkspur, CO 80118 <br /> Sign (or enter name if filing online) Print Name and Title Date: <br /> Marc Haes Marc Haes, Operations Manager 10/1212017 <br />