2021-05-17_REVISION - C1981019

• Permit No: C1981019
• IBM Index Class Name: Revision
• Doc Date: 5/17/2021
• Doc Name: Correspondence
• From: DRMS
• To: History Colorado | State Historic Preservation Office
• Type & Sequence: TR148
• Email Name: ZTT
• Email Name: JDM
• Media Type: D
• Archive: No

WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For Office Use Only
Form State of Colorado, Office of the State Engineer
GWS-31 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581
02/2017 www.water.state.co.us and [e-mail]
1.Well Permit Number: 60079-MH Receipt Number:
2. Owner's Well Designation:POC-10
3.Well Owner Name:Colowyo Coal Company L.P.
4.Well Location Street Address:5731 State Highway 13 Meeker, CO 81641
5.As Built GPS Well Location(required): []Zone 12 0 Zone 13 Easting:262906.7 Northing: 4463750.2
6. Legal Well Location: NE 1/4, SW 1/4, Sec., 26 Twp.4 N or S®, Range 93 E or W P.M.
County: Moffat
Subdivision: Lot 1 Block , Filing(Unit)
7. Ground Surface Elevation:6,401 feet Date Completed: 10/12/2019 Drilling Method: Direct Push
8. Completed Aquifer Name : Unnamed Total Depth: 25 feet Depth Completed: 25 feet
9.Advance Notification: Was Notification Required Prior to Construction? Yes No, Date Notification Given: 10/02/2019
10.Aquifer Type: []Type I (One Confining Layer) []Type I (Multiple Confining Layers) ❑Laramie-Fox Hills
(Check one) ❑Type II (Not overlain by Type III) ❑Type II (Overlain by Type III) ElType III (alluvial/colluvial)
11. Geologic Log: 12. Hole Diameter(in.) From(ft) To (ft)
Depth Type Grain Size Color Water Loc. 2.5 0 25
0-10 silt with sand fine olive
10-25 lean clay with sar fine olive
13. Plain Casing
OD(in) Kind Wall Size(in) From(ft) To(ft)
1.3 PVC .18 0 15
Perforated Casing Screen Slot Size(in): 0.010
OD(in) Kind Wall Size(in) From(ft) To(ft)
1.3 PVC .18 15 25
14. Filter Pack: 15. Packer Placement:
Material sand Type Pre Pack
Size 10/20 15
Interval 15-25 Depth
16. Grouting Record
Material Amount Density Interval Method
Remarks:
17. Disinfection: Type None Amt. Used Not Applicable
18.Well Yield Estimate Data: heck box if Test Data is submitted on Form Number GWS-39,Well Yield Test Report
Well Yield Estimate Method: Not Tested
Static Level: Estimated Yield (gpm)
Date/Time measured: _ Estimate Length(hrs)
Remarks:
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
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
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
the State Engineer considers the entry of the licensed contractor's name to be compliance with Rule 17.4.
Company Name: Email: Phone w/area code: License Number:
Tri-State GftT Inc. [e-mail] [phone]
Mailing Address:P.O. Box 33695 Denver, CO 80233-0695
Sign (or ente name if filing online) Print Name and Title Date:
Michael G.Sorensen -Sr. Manager, Fuels and Water Resources