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WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For Office Use Only <br /> Form State of Colorado, Office of the State Engineer <br /> GWS 31 31 1313 Sherman St., Room 821. Denver, CO 80203 303.866.3581 <br /> 02,12017 www.water.state.co.us and dwrpermitsontine4ustate.co.us {• .. <br /> 1.Well Permit NumberL—R69.47-p11`I 07 Receipt Number: / <br /> 2.Owner's Well Designation:LTC-GW-1 ` <br /> 3.Well Owner Name:Transit Mix Conceete 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 [D Zone 13 Easting:508355.0 Northing:4279197 <br /> 6.Legal Well Location: NW 114. NW 1;4, Sec., 16 Twp. 16 =N or S M Range_67 E or W Q 6 P.M. <br /> County: Et Paso Subdivision: Lot_- _.- -. _ Lot , Block , Filing(Unit) <br /> 7.Ground Surface Elevation:7,057 feet Date Completed: 07/20/2017 Drilling Method: Air Hammer _ <br /> 8.Completed Aquifer Name: Granite Total Depth: 103 feet Depth Completed: 95 feet <br /> 9.Advance Notification: Was Notification Required Prior to Construction? F1 Yes No. Date Notification Given: 06/16/2017 <br /> 10.Aquifer Type: OType i (One Confining Layer{ [Type I (Multiple Confining Layers) ❑Laramie-Fox Hills <br /> (Check one) ❑Type II (Not overlain by Type III) QType II (Over latn by Type III) ❑Type III (alluvial rcoltuviat) <br /> 11. Geologic Log: 12. Hole Diameter(in.) From tft) To(ft) <br /> Depth Type Grain Size Color Water Loc. 6 5/8 0 14 <br /> 0 Alluvium Sandy Gravel Light Brown 9 4 13/16 14 103 <br /> 12 Granite NA Red/Brown 9 <br /> 13. Plain Casing <br /> OD(in) Kind Wall Size(m) From(ft) To(ft) <br /> See Attached Sheet <br /> Perforated Casing Screen Slot Size (in): �_ <br /> OD tin) Kind Watt Size(in) From ift) To(ft) <br /> See Attached Sheet <br /> 14. Filter Pack: 15. Packer Placement: <br /> Material Sand Type NA <br /> Size 12-20 NA <br /> IntetvaI See Attached Depth <br /> 16. Grouting Record <br /> Material Amount Density Interval Method <br /> Remarks: Grout 29 Gat See Attached 0.17.4 Ft 'v <br /> 17. Disinfection: Type NA Amt. Used NA' <br /> 18.Well Yield Estimate Data: 7Check box if Test Data is submitted on Form Number GWS-39, Weli.Yield Test Report <br /> Well Yield Estimate Method: Peristauic Pump <br /> Static Level: See Attached Sheet TFs,,,rm,,ate�'Yield igpmi SeeAttachedDate/Time measured: Sept. 13, 2017, 9:13 AM te Length(hrs) 3 <br /> Remarks:See Attached Sheet for well completior information, <br /> 19, I have read the statements made herein and know the contents thereof a-d they are it ue tc my knowledge f his docume,t is signed i x name entered if <br /> fit ng online)and certified in a((ordance with Rule 17 4 of the water Well.nnttrucnpn Rule' I CCR 402 2 The filing of a document ti•at:ontains fa:se <br /> statements is a violation of section 17 91 1080 i,e,,C R.S and is pu,iishal-,e by fines up to„1,000 and at evot atic•i at the conua(t rig license F(ding onl ne <br /> the State Engineer considers the entry of'he lice isLd u,nuactor's iiarne it he rontphanrP with Rule'7 4 <br /> Company Name: Email: Phone w rat ea code: License Number <br /> Authentic Drilling Narc(a<)AuthenticdriLling.com i720)465 1450 151C <br /> Mailing Address:201 Perry Park Ave, P105 Larkspur, CO 80118 <br /> Sign (or enter name if filing ontine) Print Name and Title Date: <br /> Marc Haes Marc Haes, Operations Manager 10/12/2017 <br />