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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 /> 0212017 www.water.state.co.us and dwrpermitsonline�3state.co us <br /> 1,Well Permit Number ?o-7366 Receipt Number. 7 <br /> 2.Owner's Well Designation:LTC-GW-3 <br /> 3.Well Owner Name:Transit Mix Concrete Co. <br /> 4.Well Location Street Address:2485 Hitch Rack Ranch Road, Colorado S nn s. CO 80926 r So�3lE .4/' 4L7$8-6 <br /> 5.As Built GPS Well Location(required): ®Zone 12 []Zone 13 Easting:51"56.0 Northing:A249R4 <br /> 6. Legal Well Location: SE 1i4, NW 1/4, Sec., 16 Twp, 16 M N or S Q, Range 67 OE or W • 6 P.M. <br /> County: El Paso <br /> Subdivision: Lot . Block , Filing i,Umt) <br /> 7.Ground Surface Elevation:7,062 _ feet Date Completed: 07/27/2017__ Drilling Method: Air Hamrr>er <br /> 8.Completed Aquifer Name: Granite Total Depth: 202 feet Depth Completed: .94 feet <br /> 9.Advance Notification: Was Notification Required Prior to Construction? Yes No, Date Not'.fication Given: 06i 16/Z017 <br /> 10.Aquifer Type: Type 110ne Confining Layer) []Type i (Multiple Confining Layers) []Laramie-Fox Hilts <br /> (Check one) [j]Type It (Not overlain by Type Ili) []Type II (Overlain by Type I11) C3Type III (alluviat/coiluviat) <br /> 11. Geologic Log: 12. Hole Diameter(in.) From(ft) To(fti <br /> Depth Type Grain Size Color Water Loc. 6 5.8 0 9 <br /> 0 Wthered Granite -Sandy Gravel Dark Brown 8 4 13/16 9 202 <br /> 4 Granite NA Light Red 8 <br /> 12 Biotite/Muscovit NA Dark Red 8 13. Plain Casing <br /> 18 Granite NA Red 8 OD(in) Kind Walt Size(in) From(ft) To(ft) <br /> See Attached Sheet <br /> Perforated Casing Screen Slot Size (ink 3;8 _ <br /> OD(in) Kind Watt Size(m) From(ft) To(`t) <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 15 Gat See Attached 0.9 Ft °. -- <br /> 17. Disinfection: Type NA Amt. Used NA <br /> 18. Well Yield Estimate Data: Check box•f Test Data is submitted on Form Number GWS-39, Well Yield Test Report <br /> Wetl Yield Estimate Method: Peristaltic Pump <br /> Static Level: See Attached Sheet �_- _ -__ Estimated Yield (gpmi SeeAttached <br /> Date/Time measured: —Sept' 21, 2017, 9:46 AM Estimate Length ,hrs) 2 _ <br /> Remarks:See Attached Sheet for well completion information. <br /> 19. 1 have read the statemei,ts made herein and know the contents thereof and they a•e Uue to my r iowlc•dgt 1 his docuirert s signed tot name entetee ii <br /> fling online)and certified it accordance with Rule 17 4 et the Water Well Ca^st ucri,,n Rotes 2 C--k 40: 1 The tihig-if a drxi.menl that rnnta,rim'alse <br /> statements is a violation of wtinr.37 r1 1081 i pei C P 5 and is punish,ible by fir es.ip to;1.000 revat-atan cf *he rant,ar.ing nceme if iihng on111 e <br /> the State Engineer corsiders the entry ni the,liaised cantiactor s idme to be rnmNtiar,,( .v.th Rule 17.4 <br /> Company Name: Emalt: Phone w.area code: license Number: <br /> Authentic Drilling Mal CCwAuthenticdritling.cum a i720)465-1450 11510 <br /> Mailing Address:201 Perry Park Ave. #105 Larkspur, CO 80118 <br /> Sign(or enter name if filing online) Print Name and Title Date: <br /> Marc Ha es Marc Haes,Operations Manager 10;12+2017 <br />