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IrM4IKI. - <br /> n ,l WL-LL CONSTRUCTION AND I EST REPORT For ouica Uae only <br /> STAI E OF COLOnADO, OFFICE OF THE STATE ENGINEER <br /> 1. WELL PERMt1' NUMBER Al <br /> 2 OWNER NAME(S) /-fo/ni m <br /> MalIInNAddress 36*160 Co%Tads 1(,'g " 54 /2a <br /> City, St.Zip _ �,,,ct Co 7 /Z2Co <br /> Phone (7/9) 7 B iz- G ZS <br /> a VILELL,LQCAI ION 98 gRILLED SE 1/4 5t'.- 1/4. Sec. /7 Twp.� <br /> DISTANCES FROM SEC. LINES: <br /> It. from oa.-M Sec. line. and 7-50 U. Irom c 4s f Sec. line. OR <br /> -(nanirar Aalnnr --Isaerar maw _ <br /> 8U8DIVISI0N: _ _ LOT BLOCI< FILING(UNIT) <br /> _ STREET ADDRESS AT WELL LOCA'I"ION: <br /> 4, GROUND SURFACE ELEVATION ,�D✓�3•JZ It. DRILLING METHOD <br /> DATE COMPLETED 8 -22 - 9 IR TOTAL DEPTH 70 It. DEPTH COMPLETED 4-7 it. <br /> 0. GEOLOGIC LOG: 6.HOLE DIAM. (In.) Frunl (it) To (11) <br /> Dopul Dasciipllon of Material(type,Size,Color,Water Loceuon) a 0 <br /> ' 2 -2 7. PLAIN CASING <br /> Ce.« _ �S..w►_ n,�l4 OD Qn) . Kind Wail Size From(ll) To(fl) <br /> _J� pVc O_ o / <br /> P V C ,.S- g0 <br /> o --7 o r.►. a <br /> PER CASING: Screen SloL Size: to.of o ;,,. <br /> yc 3 _.17 <br /> IL FILTER PACK 8. PACKEA PLACEMENT: <br /> Material s i 1 Ica sa�s� Type <br /> Size /o-2.0 <br /> Interval ' Depth <br /> 10. .GROUTING RECORD: <br /> Material Amount Density/ htterval Placement <br /> HENARKS: /a-! a+ars <br /> re.. /o f sfd. O -/p' .or <br /> I DISINFECTION: T No N AmL Used <br /> ' "U=DATA ❑Quwk box I Test Data Is strbrtdtted on Form No. GM 39 Supplemental Well Test. <br /> • TESTING METHOD N A <br /> Staft Level ,11.85 IL DaWTkT a meastlfed 9:& Yf3 . Production Rate MIA <br /> Pumping level IL Datefrime measured ` ' .Test length Qm) <br /> Remaths ` <br /> 3. 1 have teed III statements made hetekt mW kmw 11w contents limed,tend Il d they we buc to my knowledge.[Pursuant to Section 24.4.104 (13)( <br /> CAS„In making of false statements hstsin oonsWutee par)ury In the second degas and Is punishable as a class 1 misdemeanor.) <br /> CONTRACTOR e= eo ci c� Z'��. ,Phone, 7/ o z2j Uc. No. <br /> Co 090 <br /> lame/TUIe (Please type or print) Signature Date <br />