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FORM NO. <br />GWS-31 <br />4/2012 <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St., Ste 821, Denver, CO 80203 <br />Main (303)866-3581 Fax 303 866-3589 wwwmater state. co us <br />For Office Use Only <br />. WELL PERMIT NUMBER: <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: To-,,k— Land cM cvl t <br />MAILING ADDRESS: /-O Rclr 1,,q7 <br />CITY: Gr2t,, STATE: C 0 ZIP CODE: /G.76 <br />TELEPHONE NU ER w/area code: <br />3. WELL LOCATION AS DRILLED:—ii1/4, X4/1/4, Sec.,.3 3 Twpr,�2 Cxi' N or S, ❑I Range-2Q 0 E or W 91 <br />DISTANCES FROM SEC. LINES: ;22 7 ft. from 0- N or n S section line and /,;,'g 2 ft. from 0 E or 19W 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: Z4F <br />must be meters, Datum must be NAD83, Unit must be set to true N, I 1 Zone 12 or IOI Zone 13 Easting:.2 6? 793 a <br />STREET ADDRESS AT WELL LOCATION: Northing: yy7 916 0 Y <br />4. GROUND SURFACE ELEVATION g� 777 feet DRILLING METHOD <br />DATE COMPLETED //- - q TOTAL DEPTH feet DEPTH COMPLETED feet <br />5. GEOLOGIC LOG: <br />6. HOLE DIAM in. From ft To ft <br />Depth Type Grain Size Color Water Loc. <br />r7 <br />+ ; ,9.. <br />r,,.& k <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />q� Fiucu PV( Srif MI6 <br />PERFORATED CASING: Screen Slot Size (in): . () 30 <br />1 PVC sc(/ Flo .a <br />8. FILTER PACK: <br />Material ;LxuSAwa <br />Size 9112- <br />%!ZInterval 0 40,2 <br />Interval <br />9. PACKER PLACEMENT: <br />Type <br />Depth <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />FFe (56 # 1 4-(b 4PAU,T l <br />Q�:� kretf� /GOO 0 4a 3 /PA TV <br />Remarks: <br />11. DISINFECTION: Type Amt. Used <br />12. WELL TEST DATA: ❑ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level ft. Date/Time measured: Production Rate gpm. <br />Pumping Level ft. Date/Time measured Test Length (hrs) <br />Remarks: <br />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 <br />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 <br />ocument that contains false statements is a violation of section 37-91-108(ixe), C.R.S., and is punishable by fines up to $5000 and/or revocation <br />f the contracting license. If filing online the State Engineer considers entering of licensed contractor name to be com liance with Rule 17.4 <br />Company Name: <br />ru <br />Phone w/area code: <br />20 - <br />License Number: <br />Mailin Add s: 1 v e u `d 5z4 <br />Sign (or e rn e if iling nline) <br />Print Name and Title <br />I4 <br />Date <br />-lq <br />