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

Form No. WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For Office Use Only
GWS 31 State of Colorado, Office of the State Engineer 43; REC f\/FE)
1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581li'1S �+ �`
02/2017 www.water.state.co.us and [e-mail] tic �1Q �S�'!
1. Well Permit Number: 303361 Receipt Number: 9703921K 4 �( ( 10
w!Tcf 65t7
2. Owner's Well Designation;MW-4-C ST,a?. ��SVU�C �y
EN(rl CGS
3. Well Owner Name:GCC Energy, LLC C��Lb LIEF?
4. Well Location Street Address:620 Sand Ridge Ct. Hesperus, CO 81326
5.As Built GPS Well Location (required): OZone 12 ❑Zone 13 Easting:752094.0 Northing: 4125628
6. Legal Well Location: -1/4, SE 1/4, Sec., 34 Twp.35 N or S©, Range 12 E or W 0, NM P.M.
County: La Plata
Subdivision: Vista del Oro Lot NA , Block NA , Filing (Unit) NA
7. Ground Surface Elevation:7569.4 feet Date Completed: 03/24/2017 Drilling Method: Rotary Air Hammer
8. Completed Aquifer Name : Unspecified Total Depth: 350.23 feet Depth Completed: 342.00 feet
9. Advance Notification: Was Notification Required Prior to Construction? 17 Yes ONo, Date Notification Given:
10. Aquifer Type: []Type I (One Confining Layer) ❑Type 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 38.50
0-5 topsoil silt dk yet orang NA 7.0 38.50 350.23
5-40 weath'd silts/ss silt/sand dk yet orang NA
40-320 siltstone/sandstn silt/sand med gray NA 13. Plain Casing
320-345 sandstone sand dark gray NA OD (in) Kind Wall Size (in) From (ft) To (ft)
345-346 coal (A-seam) coal black NA 8,625 STEEL 0.188 -2.35 38.50
346-349.5 carb shale clay black NA 2.375 PVC 0,218 -2.35 44.15
349.5-350.23 coal (A-seam) coal black NA
Perforated Casing Screen Slot Size (in): 0.020
OD (in) Kind Wall Size (in) From (ft) To (ft)
2.375 PVC 0.218 44.15 342.00
14. Filter Pack: 15. Packer Placement:
Material Silica Sand Type NA
Size 10-20 NA
Interval 41.15-343.00 Depth
16. Grouting Record
Material Amount Density Interval Method
Remarks:Monitoring well. Dry drilling method.Drilling services by DAK Drilling.3'X 3'X 0 5'cement ifs'bentonite chips 3 sacks NA 343.00-350.23 poured
pad installed around locking wellhead.Annular seal is hydrated 3/8"bentonite chips. SS s/s"bentonite chips 14 sacks NA 0,00-41.15 poured
centralizers installed every 40'on screen&casing. Hole dry at time of To. Free water
entered borehole overnight.
17. Disinfection: Type NA Amt. Used NA
18. Well Yield Estimate Data: Check box if Test Data is submitted on Form Number GWS-39, Well Yield Test Report
Well Yield Estimate Method: bailer
Static Level: 328.33 ftbli Estimated Yield (gpm) 0.5
Date/Time measured: 3/29/17 08:40 Estimate Length (hrs) 1
Remarks:monitoring well development by bailer surging£t 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 17.4 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 10811 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