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FORM NO WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br /> GWS-31 STATE OF COLORADO,OFFICE OF THE STATE ENGINEER ' <br /> 171412005 1313 Sherman St.,Room 818,Denver,CO 80203 <br /> one- <br /> Fax 303 8fi6-3589 httpJ/www.water,state.co.us <br /> 1. WELL PERMIT NUMBER: ' <br /> 2. WELL OWNER INFORMATION <br /> NAME OF WELL OWNER: Holcim,Inc. <br /> MAILING ADDRESS:3500 Highway 120 ' <br /> CITY:Florence STATE:CO ZIP CODE:81226 <br /> TELEPHONE NUMBER: 719 784-1118 <br /> 3. WELL LOCATION AS DRILLED: $EE1/4, SW1/4, Sec.16, Twp.19 ❑N or®S, Range 68 ❑E or®W ' <br /> DISTANCES FROM SEC.LINES: ft.from ❑N or❑S section line and ft.from ❑E or❑W section line. <br /> SUBDIVISION: NA . LOT NA. BLOCK NA FILING(UNIT)NA <br /> Optional OPS Location:GPS Unit must use the following settings: Format must be UTM,Units Owner's Well Designation.MW-13 <br /> must be meters,Datum must be NAD83,Unit must be set to true N, ❑Zone 12 or❑Zone 13 Easting: <br /> STREET ADDRESS AT WELL LOCATION:Highway 120 Northing: <br /> 4. GROUND SURFACE ELEVATION feet DRILLING METHOD Air Rotary <br /> DATE COMPLETED 04/03/09 TOTAL DEPTH 32 feet DEPTH COMPLETED 30 feet ' <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft <br /> Depth Type Grain Size Color Water Loc. 5 0 32 <br /> 3' SILT --sill sizedn gray none ' <br /> -1 .5' SANDSTONE sand It gray 15-17' <br /> 18.5-32' LIMESTONE sil sized gray none 7. PLAIN CASING: <br /> OD(in) Kind Wall Size(in) From(ft) To(ft) ' <br /> 2-inch PVC sch.40 0 15 <br /> PERFORATED CASING: Screen Slot Size(in):0.010 <br /> 2-inch PVC sch.40 15 30 <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material sand Type NA <br /> Size #10/20 <br /> Interval 13-32' Depth NA <br /> 0. GROUTING RECORD ' <br /> Material Amount Density Interval Placement <br /> Remarks: b chips bucket 1/8" 11-13' poured <br /> Grout 10 aq I std. 2-11, poured <br /> 11. DISINFECTION: Type none I Amt.Used NA ' <br /> 12. WELL TEST DATA: LJ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br /> TESTING METHOD <br /> Static Level 15^_ft. Date/Time measured:04/03/09/08:50am Production Rate NA gpm. <br /> Pumping Level NA ft. Date/TMme measured NA Test Length(hrs)NA <br /> Remarks: ' <br /> 13. I have read the statements made herein and know the contents thereof,and they are true to my knowledge. This document is signed and certified in <br /> accordance with Rule 17.4 of the Water Well Construction Rules,2 CCR 402-2. [The filing of a document that contains false statements Is a violation of <br /> section 37-91-108 1 e,C.R.S.,and is punishable by fines up to$5000 and/or revocation of the contracting license. <br /> Company Name: Phone: License Number: <br /> Mailing Address: <br /> Signature: Print Name and Title Date <br />