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FORM 40. WELL CONSTRUCTION AND TEST REPORT For office use only <br /> c STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> t1/90/90 <br /> 1. WELL PERMIT NUMBER 163756 M.W.-2 <br /> I ' OWNER NAME(S) Cotter Corporation <br /> Mailing Address 12596 West Rayau venue, #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. 2 S , Range 71 W <br /> DISTANCE$ FROM SEC. LINES: <br /> 1982 ft. from South Sec, line, and 1531 ft. from East Sec, line. OR, <br /> (north or south) (east or West) <br /> SUBDIVISION: LOT BLOCK FIUNG(UNI-Q <br /> STREET ADDRESS AT WELL LOCATION: <br /> 4. GROUND SURFACE ELEVATION 6581.3 tr, DRILLING METHOD Auger <br /> DATE COMPLETED 11/12/81 TOTAL DEPTH 22.5 ft. DEPTH COMPLETED 22.5 ft. <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM. (in.) From (ft) To (ft) <br /> Depth Description of Material(Type,Size,Color,Water Location) Orr 0 22.5 <br /> 0' - 3.5' Fill - Cs. Cobbles, some cs. <br /> gravels <br /> 5' 12.0' Boulders, cs. Gravel with, gobbles 7. PLAIN CASING � <br /> —_ And S5. to med. sand OD (in) i(Ind Wall Size From(ft) To(ft) <br /> 2-1/2' PVC Sch 40 +3.0 8.4 <br /> Same as above with increased 2-1 2 ' PVC Sch 40 13.4 15.4 <br /> gravel and sand <br /> 21 - 22.5' Bedrock, sound competent PERF. CASING: Screen Slot Size: " <br /> amghiboli-te „ . 2-1/2" PVC Sch 40 . 8:4 • 13.4 <br /> 22.5' T.D. <br /> *H it_wa tar 2 7 <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> ._Material Silica Sand ' T <br /> Size -12 Meshyp, <br /> Interval 5' 20' Depth t Y <br /> 10. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br /> REMARKS: Neat Cement 0' - 1.0' . 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 tL Date/Time measured , Production Rate gpm. <br /> Pumping level ft. Date/Time measured , Test length (hrs.) <br /> Remarks <br /> 3. I have read the statements made herein and know this contents thereof,and that they are true to my knowledge.(Putsuant to Section 244-104(1-3)(a)QKS.,the makinc <br /> of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor:) <br /> CONTRACTOR Cotter Cor oration Phone ( 303) 980-1292 Lic. No. N/A <br /> MailingAddress est 8ayaid Avenue, #350 - Lakewocd_C_0_8.0228 <br /> Na[noe aisle PI^eprrype or print) Signature Date <br /> I l�. t yy �. <br /> Mine Geologist <br />