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t+Mut>xs. <br /> a ,t WELL CONS7rRUGHON AND 7 EST REPORT ror Office Use oidy <br /> ' 81Al E OF COLORADO, OFFICE OF THE STATE ENC31NEER <br /> ' I. WELL PEnMrr NUMBER 6-4w-� <br /> 2.OWWR NAMES) /7pliV4.m �t' . <br /> Mailing Address *o 20 <br /> city,St.Zip._ ,,co�� G iL2(o <br /> Phwie (7/9) 7S+e& 2s <br /> 1 a I, 9 s CA77oN93 UBILLM SE 1/4 Sjf 1/4,See. /7 Twp., / 7 S ,RnilUe G 8 ll_ <br /> DISTANCES FROM GEC. LINES: <br /> �_It.from s... Set:. title. and 7s0 it, from�" �Sec. line. OR <br /> SUBDIVISION: _ LOT BLOCK FIUNG(UNIT) <br /> STREET ADDRESS AT WELL LOCATION: <br /> 4. GROUND SURFACE ELEVATION_ge:C3.V it. DRILLING METHOD a I r -- Ya'� a.►"�/ <br /> ' T <br /> DATE COMPLETED 8 -Z.2— 9 TOTAL DEPTH 7o IL DEPTH COMPLETED 4L 7 It. <br /> ' S. GEOLOGIC LOG: 6 HOLE DiAM. (in.) From (it) TO (It) <br /> Uapol UesclhWm of Material(rype,Size,Color,Water LocadoiQ I3 CP <br /> 7.PLAIN CASING <br /> e..• .� s...►► e„r OD ( l0nd Wail Size Fromol) To(1Q <br /> o—`70 0 _ <br /> PERF. CASING:Screen Slot Site: <br /> 8.FILTER PACK: M PACKFA PLACEMENT: <br /> Material s i iea: ?a�a Type „ <br /> Irltery� p-Zo Depth <br /> is -GROUTM RECORD: <br /> Mote" Miount Density tiitwvW Pianent:ent <br /> to Na. <br /> a... 1�.. �fd, tD - or •♦ <br /> 1 OISINFEC"TiO TymNor+f. MIL Used <br /> NU=�T& ❑m**bons Test Data is suited on Form N(L em a®Suppmmenw Wev Test. <br /> TES'{M NE MOD NR <br /> p DAW11m Pwductlon Re W,r. <br /> ' Pumping level A. DmWfirne r owured ' ' .Test length Piro <br /> Healatks • <br /> 3` i pelts NW Ow mode 1 wok find k mw Ow ooltbnb mired,wW m t they v.111111 b ON faWAKIge.(Pum d b soollon 24.4.104 pal( <br /> CAIIB,IM mdit d slatmenk hwob oondkUln P44MY In In somml doges and N Panbbabb m a cku i mbdamoanor.J <br /> CONTRACTOR ... o cq �w�L ,Phone, 7/ 2 Lic.No.� <br /> i tmo v4 C o e,ws o 0 <br /> ' Vame/Tilie (Please type or print) Signature Date <br />