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ire - `9 <br /> / M NO. CONSTRUCTION AND TEST REPORT For ael Use' n <br /> GWS_31 STA90 C LORADO,OFFICE OF THE STATE ENGINEER <br /> 04/20% 1313 Shfennan St,Room 818,Denver,CO 80203 <br /> Phone-Into(303)866-3587 Main(303)866.3W1 JUL 2 9 2 0 05 <br /> Fax 303 BW3589 http:/M-ww.water.state.co.us <br /> M-N 1. WELL PERMIUMBER: 2 5 2 `/A I?? wAT It a,Esnv��as <br /> gT TE�h:Gl;::�;{ <br /> WELL OWNER INFORMATION <br /> NAME OF WELL OWNER: r4 DISC IP t libyyojob lv . <br /> MAILING ADDRESS: f l j�D C.!2 4 <br /> CITY: Gf3 STATE: C O ZIP CODE: <br /> TELEPHONE NUMBER: 970 40 - 619S- V J ���0 r d� <br /> 3. WELL LOCATION AS DRILLED: S?E 1/4„C t'' 114, Sec. 12 , Twp. 3S ®Nor❑S, Range 12- p E or EI w <br /> DISTANCES FROM SEC.LINES: ft.from ❑N or❑S section litre and fL from ❑E or❑W section line. <br /> SUBDIVISION: _/ , LOT , BLOCK ___ _, FILING(UNIT) <br /> Optional GPS Location:GPS Unit must use the following settings: Format must be UTM,Units Owner s Well Designation: <br /> must be mete ,Datum must be NAD83,Unit must be set to true N, ❑Zone 12 or[IZone 13 tasting: <br /> m meters, <br /> STREET ADDRESS AT WELL LOCATION: Northing: <br /> 4. GROUND SURFACE ELEVATION-ZOO 0 feet DRILLING METHOD /1 A /:'/?c K N O� <br /> RATE COMPLETED T N L 2664 TOTAL DEPTH feet DEPTH COMPLETED I feet <br /> S. GEOLOGIC LOG: 6. HOLE DIAM in. 1 2"' From ft 6� To ft / - <br /> Depth Type Grain Size Color Water Loc. <br /> i <br /> 7. PLAIN CASING: <br /> OD(n) Kind Well Size(in) From' <br /> (ft) To(ft) i <br /> —6 10 ire _ i/z oc�Nn 16 <br /> PERFORATED CASING: Screen Slot Sizel(in): <br /> I <br /> 8. FILTER PACK 9. PACKER PLACEMENT: <br /> Material [T17 AVGL Type N j. <br /> Size '2 <br /> Interval r it[L-0EPt h Depth <br /> f). GROUTING RECORD <br /> ' Material Amwnt Density Interval Placement <br /> Remarks: ; - r-!N b ,4 �� <br /> 122,015 ve, of Tdr nc-trdr-LOAt 0 t- L �i41 '� / <br /> 11. DISINFECTION; Type C.LQ O-X Amt Used �!��-- <br /> 12. WELL TEST DATA Check box if Test Data is submitted on Form Number GWS 39 Supplemental We11 Test. <br /> TESTING METHOD POA4 PeP--t--' I !A THE VS i,/9 -Lf 6/1 d d?Y,/I/PLC L/i/4 ' <br /> Static Level ft. Daterrime measured: J UV 2-D04 Production Rate /S gpth. <br /> Pumping Level 1_ft Date/Time measured 3: t a N/" Test Length(hrs) 2 HA <br /> Remarks: <br /> 13. I have read the statements made herein and know the contents thereof,and they are true to my knowledge. This document is signed and certified in <br /> 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 <br /> section 37-91-1 1 e,C.R.S.,and is punishable by fines up to$5000 and/or revocation of the contracting license. � . <br /> Company e: d L 70: 90f- S 6 4 LieenselNumber <br /> Mailin Address: a i 2- <br /> Signatu2: - Print Name and Title Date <br />