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FORM WELL CONSTRUCTION AND TEST REPORT F°`°`�"�°°'Y <br /> NO. <br /> NO. <br /> OWS-31 STATE OF COLORADO,OFFICE OF THE STATE ENGINEER RECEIVED <br /> 01/93 <br /> 1. WELL PERMIT NUMBER 168169-A <br /> 2. OWNER NAME(S)Jack Wagner MAR 12 2008 <br /> Mailing Address 10 Town Plaza#90 <br /> City,State,Zip Durango CO 81301 <br /> Phone 970-764-760 WATER RESOURGES <br /> 3, WELL LOCATION AS DRILLED: %Southwest%'Sec.27 Twp.35 N,Range 11 W x P.M. <br /> ft.from North Sec.Line and ft.from West Sec.Line OR <br /> SUBDIVISION:LOT BLOCK FILING(UNIT) C�) 3iT(o,6 <br /> STREET ADDRESS AT WELL LOCATION: EASTING: 12SO760435 NORTHING:4127423 <br /> 4, GROUND SURFACE ELEVATION FT. DRILLING METHOD Air Rotary <br /> DATE COMPLETEDA 143-07. TOTAL DEPTH 400 FT. DEPTH COMPLETED 400 FT. <br /> 5. GEOLOGIC LOG: 6. HOLE DIAM.(in.) From(ft.) To(ft.) <br /> Depth Description of Material(Type,Size,Color,Water Location) 9 7/8 0-40 <br /> 61/2 40-400 <br /> 0-25 clay 7. PLAIN CASING <br /> 25-400 animas formation OD(in) Kind Wall Size From(ft)To(ft.) <br /> 7^ Steel. .188 0 40 <br /> SCH 40 0 100 <br /> 41/2 PVC SCH 40 100 120 <br /> ,41/2 PVC SCH 40 120 140 <br /> 41/2 PVC SCH 40 160 180 <br /> 41/2 PVC SCH 40 220 240 <br /> 41/2 PVC SCH 40 260 280 <br /> 4112 PVC SCH 40 300 320 <br /> 4112 PVC SCH 40 340 360 <br /> 41/2 PVC SCH 40 380 400 <br /> PERF.CASING:Screen Slot Size:.020 <br /> 4112 PVC SCH 40 140 160 <br /> 4112 PVC SCH 40 180 200 <br /> 41/2 PVC SCH 40 200 220 <br /> 4 1112 PVC, SCH 40 240 260 <br /> 41/2 PVC SCH 40 280 300 - <br /> 41/2 PVC SCH 40. 320. 340 <br /> 41/2 PVC SCH 40 360 380 <br /> 8. FILTER PACK 9.PACKER PLACEMENT <br /> Material Pee gravel Type <br /> Size N/A <br /> Interval N/A Depth <br /> 10.GROUTING RECORD: <br /> Material Amount Density Interval Placement <br /> C 7 bags 12 lbs. 0-40' Pumpo <br /> REMARKS: H2O C 35'&200' <br /> 11. DISINFECTION: Type HTH Amount Use 6 oz. <br /> 12. WELL TEST DATA:❑Check box if Test Data is submitted on Form No.GWS 39 Supplemental Well Test. <br /> TESTING METHOD Air Lift. <br /> Static Level ft.100' Date/Time measured,Production Rate 3 gpm. <br /> Pumping Level -- ft._Daterrime measured 1148-07 ,Test length(hrs;)1. <br /> Remarks <br /> 13. 1 have read the statements-made herein and know the contents thereof,and that they are true to my knowledge. [Pursuant <br /> to Section 24-4-104(13)(a)C.R.S.,the making of false statements herein cone-Mutes perjury in the second degree and is <br /> punishable as a class 1 misdemeanor.] <br /> CONTRACTOR:Beeman Bros.Drilling,Inc. Phone: (970)259-1196 Uc.No.1374. <br /> Mailing Address:PO Box 6180;Dulrango,Colorado 81301 <br /> Namefritle (Please type or print) Signature Date <br /> Matthew Beeman, Drilling Contractor .--' <br />