2019-05-03_HYDROLOGY - M1977344

• Permit No: M1977344
• IBM Index Class Name: Hydrology
• Doc Date: 5/3/2019
• Doc Name: Groundwater Monitoring Report
• From: Arcadis US
• To: DRMS
• Type & Sequence: TR6
• Annual Report Year: 2019
• Email Name: TC1
• Media Type: D
• Archive: No

FORM NO, WELL CONSTRUCTION AND TEST REPORT For Office Use Only
GWS-31 STATE OF COLORADO,OFFICE OF THE STATE ENGINEER
04/2005 1313 Sherman St.,Room 818,Denver,CO 80203
Phone—Info(303)866-3587 Main(303)866-3581
Fax vinai866-3589 hftp://www.water.state.co.us
1. WELL PERMIT NUMBER:
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: Holcim,Inc.
MAILING ADDRESS:3500 Highway 120
CITY: Florence STATE:CO ZIP CODE:81226
TELEPHONE NUMBER: 719 784-1118
3. WELL LOCATION AS DRILLED: SE1/4, SW1/4, Sec.16, Twp.19 ❑N or®S, Range 68 ❑E or®W
DISTANCES FROM SEC.LINES: ft.from ❑N or❑S section line and ft.from ❑ E or❑W section line.
SUBDIVISION: NA . LOT NA, BLOCK VJA, FILING(UNIT)NA
Optional GPS Location:GPS Unit must use the following settings: Format must be UTM,Units Owner's Well Designation. MW-13
must be meters,Datum must be NAD83,Unit must be set to true N, ❑Zone 12 or❑Zone 13 Easting:
STREET ADDRESS AT WELL LOCATION-Highway 120 Northing:
4. GROUND SURFACE ELEVATION feet DRILLING METHOD Air Rotary
DATE COMPLETED 04/03/09 TOTAL DEPTH 32 feet DEPTH COMPLETED 30 feet
5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
-Depth Type Gram Size Color Water Loc. 5 0 32
0-3' SILT t iz d It bn grayone
3-18.5' SANDSTONE med s nd It gray 15-17'
18. -32' LIMESTONE silt sized gray none 7. PLAIN CASING:
OD(in) Kind Wall Size(in) From(ft) To(ft)
2-inch PVC sch.40 0 15
' PERFORATED CASING- Screen Slot Size(in):0.010
2-inch PVC sch.40 15 30
B. FILTER PACK: 9. PACKER PLACEMENT:
' Material sand Type NA
Size #10/20
Interval 13-32' Depth NA
10. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: b chips bucket 1/8" 11-13' Poured
grout 10 aalstd. 2-11' poured
' 11. DISINFECTION: Type none Amt.Used NA
12. WELL TEST DATA: LJ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD
Static Level 15' ft. Date/Time measured:04/03/09/08:50am Production Rate NA gpm.
Pumping Level NA ft. Date/Time measured NA Test Length(hrs)NA
Remarks:
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
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
section 37-91.108 1 e,C.R.S.,and is punishable by fines up to$5000 and/or revocation of the contracting license
Company Name: Phone: License Number:
Mai inq Address:
Signature: Print Name and Title Date