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FCRM NO. IWELL CONSTRUCTION AND TEST REPORT For Office use onty <br /> a� STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> 1. WELL PERMIT NUMBER 2-1/3'r-178' R CE1vE� <br /> 2 OWNER NAME(S) 4&-, J-4.-,�0e G( <br /> Mailing Address /Z S-z < AQ r,37 Qc� <br /> City, St. Zip 071 A-&f c a s g r 3 Z- sow`w <br /> Phone (`?7 6) wp"s� c�' sa� <br /> 3. WELL LOCATION AS DRILLED: �114 114,Sec.. / J Twp. ."S V , Range /�zj✓ <br /> DISTANCES FROM SEC LINES: <br /> ft. from /�UF See. line. and , fL from rSec. line. OR <br /> SUBDIVISION: LOT BLOCK FILING(UNrT) <br /> STREET ADDRESS AT WELL LOCATION: S'* M e— dt S <br /> 4. GROUND SURFACE ELEVATION 7S0 J ft. DRILLING METHOD 14-t I I <br /> DATE COMPLETED /�' 3 L. TOTAL DEPTH Z-o tL DEPTH COMPLETED �2—a ft. <br /> 5. GEOLOGIC LOG: B. HOLE DIAM. (in.) From (ft} TV <br /> ,(ft� <br /> Depth Description of Material(Type,Size,Color,Water Location) $ �� r, N 'N U 5 <br /> 7. PLAIN CASING <br /> OD (in) Kind wail size From(ft) To(ft) <br /> PERF. fCASING: Screen Slot Size: <br /> �V <br /> & FILTER PACK: 9. PACKER PLACEMENT: <br /> Material '--r6L- C Type <br /> Size <br /> Interval Depth <br /> G r . rLl v G .,1 /q3 Z- 10. GROUTING RECORD: <br /> _. _w cu 5 e-e co to C"_ -c L ►iy 19 o Material Amount Density Interval Placement <br /> REMARKS: <br /> 1 DISINFECTION: Type C /d AmL Used <br /> WELL TEST DATA: ❑Check box if Test Data is su mitted on Form No. GWS 39 Supplemental Well Test. <br /> TESTING METHOD w aY c A <br /> Static Level ® ft. Datefrime measured , Production Rate gpm. <br /> Pumping level r� ft. DatelTme measured _ �/� _, , Test length (hrs.) /o <br /> Remarks <br /> 3. I have read the statements made herein and know the contents thereof,and that they are true to my knowledge. [Pursuant to Section 244-104(13)( <br /> C.A.S.,the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.) <br /> CONTRACTOR -e-6�� Phone j 33 7 3 'I'V Lic. No. <br /> — <br /> Mailing Address /b _Z --- C 3 cr P1-;r lu cc 5 <br /> Namo/Title (Please type or print) ,, O�fve Sign a Date <br /> 4 e rua��7.�� aLp��C � 1��� <br />