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~ <br />GW <br />ta ~ "~ <br />531 <br />m WELL CONSTRUCTION AND TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />131 r a Rm 81 v r CO 80 for Office Use only <br />t. WELL PERMIT NUMBER o~ S t~ ~ 5 5 <br />2 OWNER NAME(S) sekec~ Coo ~ C'~• <br /> <br /> <br /> <br />. Mailing Address pott 670 <br />City, Si. zip a e+•. cc~ 4i I6 <br />Phone -lp) 7, 6- 3707 <br />WELL LOCATION AS DRILLED: StJ 1!4 5 ~ 1(4, sec. a6 Twp. .S N ,Range ~ g <br />DISTANCES FROM SEC. LINES: <br />Sec. line. and 30 ft. from Sec. line. OR <br />o`Z ( ft. from ,S~ <br /> r <br />SUBDIVISION: LOT BLOCK FILING(UNIT) <br /> <br />4. STREET ADDRESS AT WELL LOCATION: <br />GROUND SURFACE ELEVATION 7S cf O ft• DRILLING METHOD Iro~<. ~_~GJ~ ~'i2`^ <br />DATE COMPLETED ~ ' ~ 6 ' O ~~ TOTAL DEPTH 19 6.5 ft. DEPTH COMPLETED I ft. <br />5. GEOLOGIC LOG: <br />Depth Description of Material (Type. Size Color, Water Location) <br />p-o'?O Soil weadi,e~c~.~t.n~~C 6. HOLCE DIAM. (in.) From (ft) 'QTo' (ft) <br />.7 • 6~ S ~ LJ..23- <br /> <br />_ gd-13~. ~-~ r S o~+ ~ .fi a <br />) _ly5'~ ~ _ ~~ 7. PLAIN CASING <br />OD (in} Kind Wall Size From(ft) To(ft) <br /> <br /> <br /> " <br /> PERF. CASING: Screen Slot Size: 0.030 <br />" <br />e <br /> 1Yq <br />go PUG o•3 <br />3.5 <br /> <br /> <br /> <br /> FILTER PACK: <br />8 PACKER PLACEMENT: <br />9 <br /> . . <br /> (~ <br /> Material ~j ~ ; e q Sca~cC TYpe <br /> <br /> Size 10-20 <br /> Irnerval t 4'7 - 19 6 Depth <br /> GROUTING RECORD: <br />0 <br /> . <br />1 <br /> Pl <br /> acement <br />Material Amourn3 Density irnerval <br />i <br />` <br />REMARKS: I N ow .~.. oy.: e u S ll eav <br />1-f <br />a.ol~t ~_ 17 <br />3 q a :d C1,.: la.~~ " B-lay u <br /> cewerd O.90 ~ " <br />1 DISINFEC'CION: Type btotie f.NO~~~orWe-ll Amt•Used <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemerttal Well Test. <br /> 7ESTtNG METHOD <br />Static Level ft. Date/'rime measured ,Production Rate gpm. <br />Pumping level 1t. Date~f]me measured ,Test length (hrs.) <br />Remarks <br />3. 1 have read the statements made herein and know the contents thereof, and that they are true to my knowledge. [Pursuant to Section 244104 (13)(a) <br />C.R.S., the making of false s~at"J`''ents he~reyin constitutes perk/u/ry in the second degree and is punishable as a class 1 misdemeanor.] <br />CONTRACTOR uJ z5 rD° ~^ /~ ^'I ~' ` ~'~ '/ ~' ~ r• ^ Phone (~/ ~=) ~~G ~GY i Lic. No.l~'3 <br />Mailin Address • v J~ h S z% •'~~ ' Y~ <br />Name/Title (Please type print) Sig re ~ Date <br />J o~ ~. <br /> <br /> <br /> <br />~~j - .. ~ ..._ <br />~, ~ '~ t= <br />