2023-01-10_PERMIT FILE - M2023001 ‎(12)‎

• Permit No: M2023001
• IBM Index Class Name: Permit File
• Doc Date: 1/10/2023
• Doc Name Note: Exhibit G - Water Information
• Doc Name: Application
• From: J-2 Contracting Company
• To: DRMS
• Email Name: PSH
• Email Name: JLE
• Media Type: D
• Archive: No

GWS-31
OZ/2017
INSTRUCTIONS FOR WELL CONSTRUCTION AND YIELD ESTIMATE REPORT
This report must be computer generated online,typed or printed in BLACK OR BLUE INK and may be reproduced by photocopy or computer generation.
Photocopy reproductions must retain margins and print quality. Attach additional sheets if more space is required. Each additional sheet must be identified
at the top by the well owner's name,the permit number,form name/number and a sequential page number, Report depths in feet below ground surface.
If filing online please see the Form Submittal,Payment Options,ft Fee Schedule.You may also save,print and email the completed form to:
[e-mail]
The form must be submitted to the State Engineer's Office within 60 days after completing the well or 7 days after the permit expiration date,
whichever is earlier. A copy of the form must be provided to the well owner.
Item Instructions:(numbers correspond with those on the front of this form)
1. Complete the well permit and receipt number.
2. Provide the Identification(owner's well designation)for the well.
3. Fill in well owner name.
4. Provide the street address where the well is located.
5. Provide the GPS location where the well was drilled(required field).
Colorado contains two(2)UTM zones. Zone 13 covers most of Colorado. The boundary between Zone 12 and Zone 13 is the 108a'Meridian(longitude).
West of the 1081h Meridian is UTM Zone 12 and east of the 108`"Meridian is UTM Zone 13. The 1081 Meridian is approximately 57 miles east of the
Colorado-Utah state line. On most GPS units,the UTM zone is given as part of the Easting measurement,e.g. 12TO123456. Check the appropriate
box for the zone.
6. Complete the legal description location of the well and county, For wells located in subdivisions,the name,lot,block,and filing,must be provided.
7. Report the ground surface elevation in feet above sea level if available. This value may be obtained from a topographic map. Provide the date the
well was completed and describe the drilling method used to construct the well.
8. Indicate the aquifer in which the well was completed,the total depth drilled,and the actual completed depth of the well.
9. Indicate whether or not the well inspection team was required to be notified prior to construction. If required,provide the date notification was given.
See https://dwr.cotorado,gov/services/welt-construction-inspection for more information on Notifications.
10. Check the box indicating the type aquifer in which the welt is completed(See Rule 5.2.2 Well Construction Rules).
11. Fully describe the materials encountered in drilling. Do not use formation names unless they are in conjunction with a description of materials. Examples
of descriptive terms include:
Type-sandstone,sand,etc.
Grain size-Boulders,gravel,sand,silt,clay,etc.
Color-Denote for all materials,most critical in sedimentary rock
Water Location-Depth where water is encountered(if it can be determined)
12. Provide the diameters of the drilled borehole.
13. The outside diameter, type,wall thickness,and interval of plain and perforated casing lengths must be indicated. For perforated casing,the screen
size must be indicated.
14. Indicate the material and size of filter pack(e.g.sand.gravel.etc.)and the interval where placed.
15. Indicate the type and setting depth for any packers installed.
16. The material,amount,and interval of the grout slurry must be reported. Density may be indicated as pounds per gallon,gallons of water per sack,
total gallons of water used,or number of sacks used,etc. Specify the grout placement method,i.e.tremle pipe or positive placement. The percentage
of additives mixed with the grout should be reported under remarks.
17. Record the type and the amount of disinfection used,how placed,and the length of time left in the hole.
18. Report Well Yield Estimate data as required by Rule 17.1.1. Spaces are provided to report all estimates made during the assessment. The report should
show that the estimate comptied with the provisions of the rules. If available,report clock time when measurements were taken. If an estimate was
not performed,explain when it will be done. A full Welt Yield Test may be performed instead of an estimate; if so,check the appropriate box and
submit the data on form GWS39.
19. Fill in Company Name,Email,and Address and License Number(or PE/PG)of the Individual who is responsible for the welt construction. The licensed
contractor or authorized individual responsible for the construction of the well must sign or if filing online,enter his/her name on the report. If filing
online the State Engineer considers the entering of the licensed contractors name on the form to be a certification of accuracy and truthfulness in
compliance with Rule 17.4 of the Water Well Construction Rules and Regulations,2 CCR 402-2.
Rule 17.4 Certification • Work reports must be signed and certified as to accuracy and truthfulness of the information on the report by the welt
construction or pump Installation contractors or authorized individuals responsible for the work performed by them or under their direction or
supervision,or by the private driller or private pump installer if the work was performed by them. Such reports are deemed to be completed,signed
and certified under oath.
Submit completed report to:State of Colorado,Office of the State Engineer, 1313 Sherman St,Room 821,Denver,CO 80203. You may also save,print,scan
and email the completed form to [e-mail]
IF YOU HAVE ANY QUESTIONS regarding any item on this form,please call the Division of Water Resources Ground Water Information Desk(303-866-3587),or
the nearest Division of Water Resources Field Office located in Greeley(970-352-8712),Pueblo(719.542-3368),Atamosa(719.589-6683),Montrose
(970-249.6622),Glenwood Springs(970.945.5665),Steamboat Springs(970-879.0272),or Durango(970-247.1845),or refer to our web site at dwr.colorado.eov
for general information,forms,online filing instructions and access to state rules and statutes.