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WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For Office Use Only <br /> Form State of Colorado, Office of the State Engineer <br /> GWS 31 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 <br /> 02/2017 www.water.state.co.us and dwrpermitsonline@state.co.us <br /> 1.Well Permit Number: 60070-MH Receipt Number: <br /> 2. Owner's Well Designation:POC-2 <br /> 3.Well Owner Name:Colowyo Coal Company L.P. <br /> 4. Well Location Street Address:5731 State Highway 13 Meeker, CO 81641 <br /> 5.As Built GPS Well Location(required); Zone 12 E]Zone 13 Easting:262537.9 Northing:4466947.9 <br /> 6. Legal Well Location: NW 1/4, SE 1/4, Sec., 14 Twp.4 Ej N or S[], Range 93 E or W • 6 P.M. <br /> County: Moffat <br /> Subdivision: Lot 8 Block , Filing(Unit) <br /> 7. Ground Surface Elevation:6,297 feet Date Completed: 10/09/2019 Drilling Method: Direct Push <br /> S. Completed Aquifer Name: Unnamed Total Depth: 25 feet Depth Completed: 25 feet <br /> 9.Advance Notification: Was Notification Required Prior to Construction? F1 Yes QNo, Date Notification Given: 10/02/2019 <br /> 10. Aquifer Type: []Type I (One Confining Layer) ❑Type I (Multiple Confining Layers) ❑Laramie-Fox Hills <br /> (Check one) []Type II (Not overlain by Type Illy ❑Type II (Overlain by Type III) ElType III (alluvial/colluviai) <br /> 11. Geologic Log: 12. Hole Diameter(in.) From(ft) To(ft) <br /> Depth Type Grain Size Color Water Loc. 2.5 0 25 <br /> 0-24 Silt with sand very fine to fii light brown <br /> 24-25 ravel/sand fine to coarse tan <br /> 13. Plain Casing <br /> OD(in) Kind Wall Size(in) From(ft) To(ft) <br /> 1.3 PVC .18 0 15 <br /> Perforated Casing Screen Slot Size (in): 0.010 <br /> OD(in) Kind Wall Size(in) From(ft) To(ft) <br /> 1.3 PVC .18 15 25 <br /> 14. Filter Pack, 15. Packer Placement: <br /> Material sand Type pre pack <br /> Size 10/20 15 <br /> Interval 15.25 Depth <br /> 16. Grouting Record <br /> Material Amount Density Interval Method <br /> Remarks: <br /> 17. Disinfection: Type None Amt. Used Not Applicable <br /> 18.Well Yield Estimate Data: Check box if Test Data is submitted on Form Number GWS-39, Well Yield Test Report <br /> Well Yield Estimate Method: Not Tested <br /> Static Level: Estimated Yield (gpm) <br /> Date/Time measured: Estimate Length (hrs) <br /> Remarks: <br /> 19. 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 <br /> filing online)and certified in accordance with Rule 17.4 of the Water Well Construction Rules,2 CCR 402 2. The filing of a document that contains false <br /> statements is a violation of section 37 91 108(1)(e),C.R.S.,and is punishable by fines up to$1,000 and/or revocation of the contracting license. If filing online <br /> the State Engineer considers the entry of the licensed contractor's name to be compliance with Rule 17.4. <br /> Company Name: Email: Phone w/area code: License Number: <br /> Tri-State G&T Inc. mgsorensen@tristategt.org (303)254-3208 <br /> Mailing Address:P.O. Box 33695 Denver, CO 80233-0695 <br /> Sign (or enter ame if filing online) Print Name and Title Date: <br /> Michael G.Sorensen - Sr. Manager, Fuels and Water Resources /z 3 <br /> G I` <br />