2021-09-07_REVISION - M1973021 (4)

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WELL CONSTRUCTION AND YIELD ESTIMATE REPORT For Office Use Only Form No. State of Colorado, Office of the State Engineer GWS-31 1313 Sherman St., Room 821, Denver, CO 80203 303.866.3581 0212017 www.water.state.co.us and dwrpermitsonline@state.co.us 1. Well Permit Number: 60113 Receipt Number: 2. Owner's Well Designation:MW-2019-01 3. Well Owner Name:Jeremy Deuto 4. Well Location Street Address: 18131 CO-8 5. As Built GPS Well Location (required): ❑Zone 12 E Zone 13 Easting:482518.0 Northing: 4386159 6. Legal Well Location: SE 1/4, NE 1/4, Sec., 10 Twp.5 ❑ N or S 0, Range 70 E or WE], 6 P.M. County: Jefferson Subdivision: Lot Block , Filing (Unit) 7. Ground Surface Elevation: 6645.615 feet Date Completed: 10/22/2019 _ Drilling Method: Wireline core 8. Completed Aquifer Name : Total Depth: 246.4 feet Depth Completed: 246.4 feet 9. Advance Notification: Was Notification Required Prior to Construction? 0 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) OType 11 (Not overlain by Type III) ❑Type 11 (Overlain by Type III) ❑Type III (alluvial/colluvial) 11. Geologic Log: 12. Hole Diameter(in.) From (ft) To (ft) Depth Type Grain Size Color Water Loc. 4 0 246 0-27 Overburden 27-246.4 Precambrian B. 13. Plain Casing OD (in) Kind Wall Size (in) From (ft) To (ft) 1 PVC Sch 80 0 225 1 PVC Sch 80 245 246 Perforated Casing Screen Slot Size (in): OD (in) Kind Wall Size (in) From (ft) To (ft) 1 PVC Sch 80 225 245 14. Filter Pack: 15. Packer Placement: Material Silica Sand Type Size 10/20 Interval 219-245 Depth 16. Grouting Record Material Amount Density Interval Method Remarks: Precambrian Basement B/C Grout 0-215 tremie Bent. Chips 215-219 17. Disinfection: Type N/A Amt. Used 18. Well Yield Estimate Data: ❑Check box if Test Data is submitted on Form Number GWS-39,Well Yield Test Report Well Yield Estimate Method: N/A Static Level: Estimated Yield (gpm) Date/Time measured: Estimate Length (hrs) Remarks:Groundwater monitoring well for use in periodic sampling. 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: GEI Consultants, Inc. alockman@geiconsultants.com (303) 264-1096 N/A Mailing Address:4601 DTC Boulevard, Suite 900, Denver, CO 80237 Sign (or enter name 'Filing onl.ir,-- ) Print Name and Title Date: Andrew Lockman 02/10/2020