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 303 866-3581 Fax [phone] www.water.state.co us
For Office Use Only
1. WELL PERMIT NUMBER: /y1 -530�U
2. WELL OWNER INFORMATION /
NAME OF WELL OWNER: 1,,gS -`k J cA
MAILING ADDRESS: Po 80X- f87
CITY: STATE: ZIP CODE: (94 ,219
TELEPHONE NU ER w/area code:
3. WELL LOCATION AS DRILLED:. IW -1/4, A1W 1/4, Sec., 33 Twp 9 Nor S, rl Range 90 ❑ E or W �9
DISTANCES FROM SEC. LINES: .227 ft. from K N or F S section line and 1.24 2 ft. from ❑ E or 10 W 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: GLFI/-
must be meters, Datum must be NAD83, Unit must be set to true N, F71 Zone 12 or 1171 Zone 13 Easting:_ 219 71935
STREET ADDRESS AT WELL LOCATION: Northing: 1%
4. GROUND SURFACE ELEVATION 61 77 7 feet DRILLING METHOD A -
DATE COMPLETED ll-;?;2-11,(_TOTAL DEPTH Y-5 feet DEPTH COMPLETED feet
5. GEOLOGIC LOG:
6. HOLE DIAM in. From ft To ft
Depth
Type Grain Size Color Water Loc.
7 Q 5
i e
l I ,.
30 io 38
d k �L
7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
G S . fAs o .29
'l= FLA it AvL scu uo _ u
PERFORATED CASING: Screen Slot Size (in): . 030
U i FLOS 0 pyt jr» 4I1 l cl 1-15
36 6 y0
C
o 10 q,§
► IjSj G"ej 014
8. FILTER PACK:
Material Lira Lw a
Size 2(/7 -
Interval 1, Ns
9. PACKER PLACEMENT:
Type
Depth
10. GROUTING RECORD
Material Amount Density Interval Placement
o-, SO 5,1, °le s ( 0 4,1 q ?W.,0_
(-6,tT" PEL f2,S5,1 /7 4-0 lU ; t
Jc 250r+ oto
Remarks:
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(1)(e), 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 compliance with Rule 17.4
Company Name:
O.A.0
Phone w/area code:
License Number:
Mailing A ress: Lak4 IS,Z 4
Sign (or er if f- g 417, onl' e)
Pr' t Name and Title
Date