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FORM NO. WELL CONSTRUCTION AND TEST REPORT ' For office use only <br /> 1/931 <br /> 1 0 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> 1/9 <br /> 1. WELL PERMIT NUMBER 163755 M.W.--i <br /> OWNER NAME(S) Cotter Corporation <br /> Mailing Address 12596 nest Ba and Avenue #350 <br /> City, St. zip Lakewood, Colorado 80228 <br /> Phone ( 303 ) 980-1292 <br /> 3. WELL LOCATION AS DRILLED: NW 1/4 SE 1/4, Sec. 25 Twp. 1 S , Range 71 W <br /> DISTANCES FROM SEC. LINES: <br /> 2165 ft. from South Sec. line. and 1773 ft. from East Sec. line. OR <br /> (north or south) (east or west) <br /> SUBDIVISION: LOT BLOCK FILING(UNM <br /> STREET ADDRESS AT WELL LOCATION: <br /> 4. GROUND SURFACE ELEVATION 6590.4 ft. DRILLING METHOD Auger <br /> DATE COMPLETED 11-12-81 TOTAL DEPTH 25.5 ft. DEPTH COMPLETED 25.5 ft. <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM. (in.) From (ft) To <br /> 5(ft� <br /> Depth Description of Material (Type, Size, Color,Water Location) <br /> 0' - 3' Fill - cs. -angular cobbles with <br /> sine cs, gravels <br /> Brown cs. gravel wifh cobbles 7. PLAIN CASING <br /> and cs. to med. sand 00 (in) Kind Wall Size From(ft) To(ft) <br /> 2-1 2" PVC Sch 40 +2.5 17.0 <br /> 13' - 17' Fine to cs . sand gravelly and 2-1/2" PVC Sch 40 22.0 24.0 <br /> silty <br /> 17' - 23' Fine to cs. silty sand with PERF. CASING: Screen Slot Size: -17 — <br /> ' 5Qmp gravel 2-1/2" PVC Sch 40 17.0 } <br /> 23 - 25.5' Bedrock, competent amphibolite <br /> 25.5 T.D. <br /> 8. FILTER PACK: S. PACKER PLACEMENT: <br /> *Hit. water @ 7.0' Material Si 1 i ca'-Sand Type <br /> Size 8-1Z, Mesh <br /> Interval 35, - 94 t Depth <br /> 10. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br /> REMARKS: Neat Cement 0' - 1.5' Manually <br /> 1 DISINFECTION: Type Amt. Used <br /> WELL TEST DATA: ❑ Check box if Test Data is submitted on Supplemental Form. <br /> TESTING METHOD <br /> Static Level ft. Date/Time measured , Production Rate gpm. <br /> Pumping level ft. Date/Time measured , Test length (hrs.) <br /> Remarks <br /> 3. 1 have read the statements made herein and know the contents thereof,and that they are true to my knowledge.[Pursuant to Section 24-4-104(13)(a)C,R.S.,the making <br /> Of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.) <br /> CONTRACTOR Cotter Corporation Phone ( 303) 980-1292 Lie, No. _NA <br /> Mailing Address 12596 West Sayaud Avenue, #350 - Lakewood CO 80228 <br /> Name/Title (Please type or print) Signature, Date <br /> Thomas C. Lepry <br /> Pliine Geologist _-- <br />