2020-06-25_REVISION - C1981035 ‎(34)‎

• Permit No: C1981035
• IBM Index Class Name: Revision
• Doc Date: 6/25/2020
• Doc Name Note: King II App 4‎(5)‎ DWR Data Sheets
• Doc Name: Proposed Revision Materials
• From: GCC Energy, LLC
• To: DRMS
• Type & Sequence: PR10
• Email Name: JHB
• Email Name: THM
• Media Type: D
• Archive: No

WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For OfF my
Form No. State of Colorado, Office of the State Engineer i
GWS-31 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 11'�N15
02/2017 www.water.state.co.us and [e-mail] �1a1 A)G I ZGj�
1. Well Permit Number: 303360 Receipt Number: 9703921Jr'TE,q
2. Owner's Well Designation:MW-4-A SrAT FNG C jWS
3. Well Owner Name:GCC Energy, LLC �� 1�, Coto R
4. Well Location Street Address:620 Sand Ridge Ct. Hesperus, CO 81326
5. As Built GPS Well Location (required): DZone 12 0 Zone 13 Easting: 752099.0 Northing:4125634
6. Legal Well Location:X- 1/4, SE 1/4, Sec., 34 Twp.35 0 N or S©, Range 12 =E or W M NM P.M.
County: La Plata
Subdivision: Vista del Oro Lot NA , Block NA Filing (Unit) NA
7. Ground Surface Elevation:7570.9 feet Date Completed: 03/09/2017 Drilling Method: Rotary Air Hammer
8. Completed Aquifer Name : Unspecified Total Depth: 367.85 feet Depth Completed: 366.85 feet
9. Advance Notification: Was Notification Required Prior to Construction? Yes E]No, Date Notification Given:
10. Aquifer Type: Type I (One Confining Layer) E]fype I (Multiple Confining Layers) Laramie-Fox Hills
(Check one) ©Type II (Not overlain by Type 111) [Type II (Overlain by Type III) ©Type III (alluvial/colluvial)
11. Geologic Log: 12. Hole Diameter (in.) From (ft) To (ft)
Depth Type Grain Size Color Water Loc. 12.0 0.00 39.00
0-5 topsoil silt dk yet orang NA 7.0 39.00 367.85
5-40 weath'd silts/ss silt/sand dk yet orang NA
40-327.5 siltstone/sandstn silt/sand med gray NA 13. Plain Casing
327.5-328 carb shale clay black NA OD (in) Kind Wall Size (in) From (ft) To (ft)
328.343 sandstone sand med gray NA 8.625 STEEL 0,188 -3.50 39.00
343-343.5 coal (A-seam) coal black NA 2.375 PVC 0.218 -2.89 349.00
343.5-347.5 carb shale clay black NA
347.5-349 coal (A-seam) coal black NA
349-349.5 carb shale clay dark gray NA Perforated Casing Screen Slot Size (in): 0.020
349.5-350 coal (A-seam) coal black NA OD (in) Kind Wall Size(in) From (ft) To (f0
350-359 siltstone silt med gray NA 2.375 PVC 0.218 349.00 366.85
359-359.5 sandstone sand light gray NA
359.5-361 coal (A-seam) coal black NA
361-364 carb shale clay black NA
364-367.85 siltstone silt med gray NA 14. Filter Pack: 15. Packer Placement:
Material Silica Sand Type NA
Size 10-20
Interval 346.00-367.85 Depth NA
16. Grouting Record
Material Amount Density Interval Method
Remarks:Monitoring well. Dry drilling method.Drilling services by OAK Drilling,X X TX 0.5'cement 1,f bentonite pellets (2)5-gal pails NA 340.60.346.00 tremie poured
pad installed around locking wellhead.Annular seal is 14 gal potable water per 1 sack grout EnviroPlug Grout 34 sacks 10.2 lb/gal 0.00-340.6D tremie pumped
for 30/o bentonito solids. 55 centralizers installed toplbottom of screen section and every
40'on casing. Hole dry at time of TD. Free water entered borehole overnight.
17. Disinfection: Type NA Amt. Used NA
18. Well Yield Estimate Data: DCheck box if Test Data is submitted on Form Number GWS-39,Well Yield Test Report
Well Yield Estimate Method: bailer
Static Level: 338.71 ftbgs lEstimated Yield (gpm) 0.5
Date/Time measured: 3/29/17 08:30 Estimate Length (hrs) 1.5
Remarks:monitoring well development by bailer surging ft production
19. 1 have read the statements made herein and know the contents thereof,and they are true to my knowledge. This document is signed(or name entered if
filing online)and certified in accordance with Rule 17A 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$1,000 and/or revocation of the contracting license. If filing online
the State Engineer considers the entry of the licensed contractor's name to be compliance with Rule 17.4.
Company Name: Email: Phone w/area code: License Number:
Resource Hydrogeologic Services, Inc. [e-mail] [phone] NA
Mailing Address:101 W 11th St#103 Durango, CO 81301
Sign (or enter name if filing online) Print Name and Title Date:
Landon Beck Landon Beck- Principal Hydrogeologist 08/17/2017