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13EG'EMD FORM so. <br /> wsal GW5�31 WELL CONSTRUCTION AND TEST REPORT For dffice Use only <br /> Imo+ STATE OF COLORADO, OFFICE OF THE STATE ENGINEER jQV C ' 2004 <br /> Ij WELL PERMIT NUMBER �,,.ATZI I <br /> GOLO. <br /> 2 OWNER NAME(S) / C LG <br /> Mailing Address <br /> CitY, St. Zip S <br /> Phone ( ) <br /> 3. WELL LOCATION AS DRILLED S 1/4 S GU <br /> DISTANCES FROM SEC. LINES: 1/4, Sec. 2- 1 Twp. 3 _-AL, Range <br /> 00 ft fromrSec. line. and„�S D `ft. from�Sec. line. OR <br /> SUBDIVISION:/ti�f,���� ,��r�2,,o LOT 3 BLOCK FILING(UNrT) <br /> STREET ADDRESS AT WELL LOCATION: <br /> 4. GROUND SURFACE ELEVATION ft. DRILLING METHOD led 6,L1,1 <br /> DATE COMPLETED /O G TOTAL DEPTH jeG ft. DEPTH COMPLETED <br /> 5.Depth <br /> LOG: 6. HOLE DIAM. (in.) From (ft) TO (ft) <br /> > Description of Material (type,Size, Color,Water Location) 9 -_ <br /> 4�0 <br /> 7. PLAIN CASING <br /> OD (in) Kind Wall Size From(ft) To(ft) <br /> zo <br /> 47 <br /> PERF. CASING: Screen Slot Size: <br /> v <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material Type <br /> Size 3j <br /> Interval -2 90 /�G(� ` Depth <br /> 10. GROUTING RECORD: <br /> REMARKS: Material Amount Density Interval Placement <br /> 1 DISINFECTION: Type f j Amt. Used12 z s <br /> WELL TEST DATA: ❑Che box if T ata is submitted on Form No. GWS 39 Supplemental Well Test. <br /> TESTING METHOD // <br /> Static Level tL Datefrime measured -F110 OL 5'_ 7,Lo Production Rated _�gpm. <br /> Remarks <br /> Pumping level _ _ft Date�me measured , Test length (hrs.)- <br /> 3. 1 have read the statements made herein and know the contents thereof,and that they are true to my knowledge. [Pursuant to Section 24-4-104 (13)(a <br /> C.R.S.,the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.] <br /> CONTRACTOR Phone ( ( Uc. No. <br /> Mailin Address C � o <br /> Name/Title (Please type or pri ) Siariffurem, Date <br />