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WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For-Off-trte Use orgy <br /> Form <br /> Fo No. _ l�. - <br /> rmGWS 31 State of Colorado. Office of the State Engineer <br /> 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> 02/2017 www.water.state,co.us and dwraerm:tsonitne, state co i:s u <br /> 1,Well Permit Number:-56844-tW 30 7A2, Receipt Number: / <br /> 2.Owner's Well Designation:LTC-GW-S ' <br /> 3,Well Owner Name:Transit Mix Concrete 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 E]Zone 13 Easting:508873.0 Northing:4278664 <br /> 6. Legal Well Location: SE 114, NW_ 114, Sec., 16 _ Twp. 16 N or S 0 Range-67 E or W 6 P.M. <br /> County: Et Paso _ _" <br /> Subdivision: _" "- _ _ _--.-- Lot---. Block , Fiting (Unit; <br /> 7.Ground Surface Elevation:7,288 feet Date Completed: 08/02/2017 Drilling Method: Air Hammer <br /> S.Completed Aquifer Name: Granite Total Depth: 395 feet Depth Completed: 395 feet <br /> 9.Advance Notification: Was Notification Required Pnor to Construction? M Yes No, Date Notification Given: 7_ _ <br /> 10. Aquifer Type: ❑Type I tOne Confining Layer) [jyype I (Multiple Confining I avers) ❑Laramie-Fox Hills <br /> (Check one) []Type II (Not overlain by Type 111) ❑Type 11 (Overlain by Type III) ❑Type III(atluviaticottuviat) <br /> 11. Geologic Log: 12, Hole Diameter(in,) From(ftI To tft) <br /> Depth Type Grain Size Color Water Loc. 12 0 1 <br /> 0 Granite NA Red 413116 1 395 <br /> 395 <br /> 13. Plain Casing <br /> OD(in) Kind Watt Size(m) From ift) ?o(ft) <br /> See Attached Sheet <br /> Perforated Casing Screen Slot Size onl: "- NA <br /> OD (m) Kind Wall Size 1mm From Ift) To(ftI <br /> See Attached Sheet <br /> 14. Filter Pack: 15. Packer Placement: <br /> Material NA Type NA <br /> Size NA <br /> interval __ NA Depth NA <br /> 16. Grouting Record <br /> Material Amount Density interval Method <br /> Remarks: Grout 715 Gat See Attached 0.395 Ft <br /> 17. Disinfection: Type NA Amt. Used NA <br /> 18. Well Yield Estimate Data: Check box if Test Data is submitted on Form Number GWS-39,Wet Yield Test Report <br /> Welt Yield Estimate Method: Vibrating Wite Piezometer <br /> Static Level: See Attached Sheet —_ Estimated Yield igpmi _NA_ <br /> Date./Time measured:librating Wire Piezometer Estimate Length(hrs) NA_— <br /> Remarks:See Attached Sheet for welt completion information. Hole was abandoned. <br /> 19. 1 have read the statements made herein and know the contents thercol,anc they are t,ue tc,ny knowicdge This do<.zment Is signed for name entered if <br /> tiling online)and certi'led n accordance mth Rule 17 4 of the Water Wet:Construction P.Ae:,2(CR 402 2 The filing or a document that contains fa.se <br /> statements is a violation of section 37 91 10811 pe) C 9 S and is punishable by f ne5,,p:o S' 000 and-nr evo(ation nt vie ccnt•aomg,icense f fit ng ont ne <br /> the State Engineer considers the entry of the acensed co,warnr's Maine tc tx coiuphau,e witl:Rute+'4 <br /> Company Name: ,Email: jPhone w'area code: License Number- <br /> Authentic Drilling MarcGAuthenticdrilling-corn (720)465-1450 1510 <br /> Mailing Address:201 Perry Park Ave. k105 larkspur, CO 80118 <br /> Sign(or enter name if filing online) Print Name and Title Date: <br /> Marc Haes Marc Haes, Operations Manager 10/'2120!7 <br />