2020-12-21_PERMIT FILE - C1981010 ‎(17)‎

• Permit No: C1981010
• IBM Index Class Name: Permit File
• Doc Date: 12/21/2020
• Doc Name: Design & Construction for GW Monitoring Wells
• Section_Exhibit Name: APPENDIX V PART C
• Media Type: D
• Archive: No

FORM No.
GWS -31
4/2012
WELL CONSTRUCTION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St, Ste 821, Denver, CO 80203
Main [phone] Fax [phone] www.water state.co.us
For Office Use Only
1. WELL PERMIT NUMBER:
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: W;� I `ct.wls Vcrlr
MAILING ADDRESS: O 60X 18,7
CITY: STATE: CQ ZIP CODE: ,2
TELEPHONE NUM ER w/area code:
3. WELL LOCATION AS DRILLED: -&W1/4, A_ 1/4, Sec., :33 Twp_ X Nor S, F-1 Range -?Q ❑ E or W 91
DISTANCES FROM SEC. LINES: ;,27 ft. from 157, N or I S section line and 1.2 6/ ft. from ❑ E or 04W section line.
SUBDIVISION: , LOT BLOCK. FILING (UNIT)
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: L -V -
must be meters, Datum must be NAD83, Unit must be set to true N, 1-7I Zone 12 or 19 Zone 13 Easting: ;2 9 7 933
STREET ADDRESS AT WELL LOCATION: Northing: 4'�17 MO %
4. GROUND SURFACE ELEVATION 9777 feet DRILLING METHOD /it Lildai
DATE COMPLETED _ _ let TOTAL DEPTH feet DEPTH COMPLETED 3 feet
5. GEOLOGIC LOG:
6. HOLE DIAM in. From ft To ft
Depth
Type Grain Size Color Water Loc.
r71 � (� 35
�5
-5 V/ 433
L
14 16 30
OeLlatj rp-L M3 .t a
40 3A
I.JS
7. PLAIN CASING:
OD in Kind Wall Size (in) From (ft) To (ft)
�f iz �I/f CLuSµ S[d 14D 4-3. Q _
PERFORATED CASING: Screen Slot Size (in): .030
(yL rtusrl Seri HD 201 _ -.732
No
d. fL
O
I ISSCut,
"d e.
Coct /L dillti d
�k Baa
4&, to 24a
,
Ob o O
! .4 dle,1s k k
Z6.r
8. FILTER PACK:
Material Sa.1w JA.p
Size 9
Interval 3P 10 / s
9. PACKER PLACEMENT:
Type
Depth
a/
10. GROUTING RECORD
Material Amount Density Interval Placement
A?ayr 34eA&j.aa`% / u ., i. 0 4o 39' C'Ma,ry I)
ram
6Rour Seo s 516 eL 0 46 /FIs /-"&47 do o-leom
6APeuco 'I; AdLitir R02.M
Remarks: Cd.,<
?U. �jAJ
so,�j 4t t5 4o vl A, L o t„ t, gl
.2VU qj 4�JUE h 11t4daC.
�i u ed
ilii }fo
11. DISINFECTION: Type I Amt. Used
12. WELL TEST DATA: ❑ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD
Static Level ft. Date/Time measured: Production Rate gpm.
Pumping Level ft. Date/Time measured Test Length (hrs)
Remarks:
13. 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
ocument that contains false statements is a violation of section 37-91-108(11 He), C.R.S., and is punishable by fines up to $5000 and/or revocation
f the contracting license. If filing online the State Engineer considers entering of licensed contractor name to be com /lance with Rule 17.4
Company Name:
LA SriirN
Phone w/area code:
5,70 - g s -19 F0
License Number:
13111
Mailin ddress: 20, 1�vx cfy Lt O 'i
Sign o en r am fill online)
PrrinWarne and Title
r
Date
12-21- /,/