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`°""' "°' WELL CONSTRUCTION AND TEST REPORT For Office Use onl <br />GWS31 y <br />uvv+ STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />13 a t. 81 De v r CO 020 <br />~. WELL PERMff NUMBER o2 S ~ `~ 5 ~ <br />2 OWNER NAME(S) 52 ~@ c a. Coe ~ C v <br />Mailing Address ~ox 6'10 <br />City, St. Zip ~~dn,.,. co g t 639 <br />Phone (q-tv) ~ 6 - ! 307 <br />3. WELL LOCATION AS DRILLED: St.J 1/4 5 lJ 1/4, Sec. a 6 Twp.~_~_, Range ~ <br />DISTANCES FROM SEC. LINES: <br />f a a ~ ft. from Sowt Sec. line. and 3 d ft. from Sec. line. OR <br />SUBDIVISION: LOT~BLOCK FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION 7S9O ft. DRILUNGMETHOD Iro--{•c.vy~~o<d~ <br /> DATE COMPUTED G - ~ S - O `~ .TOTAL DEPTH a 0 6- S fc DEpTI-I Cp pLETED aO 6 • ~"~ ft, <br />5. GEOLOGIC LOG: <br />Depth Description of Material (type, S¢e, Color, Water Location) <br />O-~D Soi(Jttec.•Ilovt~ Vec-~ 6. HOLE DIAM. (in.) From (ft) To (ft) <br />.S• G 2 ~ _~ ao6.5 <br />a° -~~ 5 \ tt4Jo NP C~v ~Q <br />75-T8 Coal-l.~~aofC <br />78-t3o 3 SI Id~sde~,o~ sL.>I~e <br />13u-I'13 - rR <br />j 1'{3-loo Say.cQsJoae ~St lds ewe. Fs a <br />100-106 Cotil-Sa~2 G.. <br />7. PLAIN CASING <br />OD in) Kind Wall Size From(ft) To(ft) <br />X60 PUc. Q. 3 " O aot.6 <br /> <br /> <br /> PERF. CASING: Screen Slot Size: D • O 30 " <br /> 3• S ~Sopy~ 0.3" aot.6 6. <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> n( <br /> ~ <br />Material 5 i ~ icg SaMV( Type ~ <br /> <br />Size 1p-2 V _ <br /> Interval f q _Y.5 -~oG-S Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material .Amount Density Interval Placement <br />REMARKS: 1 t cnwde.A ¢ o 'd ~.b I¢ <br />3l~ri ~0 ek mw id. C~.:PS X1:0 ~ ~ ~1 g_ ($p-IQ~ r~kv~ <br />16.6~'~ $_)4S0 r;N~.N <br /> C9• O 3 o O_ rt <br />1 DISWFEC770N: Type blOke~t.~ou.:~ov. We( Amt. Used <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemernal Well Test. <br /> TESTING METHOD <br /> Static Level ft. Date/1•ime measured ,Production Rate gpm. <br /> Pumping level ft. DatefTme measured ,Test length (hrs.) <br /> Remarks <br />3. 1 have read the statements matle herein and know the contents thereof, and that they are true to my knowledge. (Pursuant to Section 24-4.104 (13) (a) <br />C.R.S., the making of false statemerit5 herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.) <br />CONTRACTOR ~~s~tr~ /}rr.~°•U ^- ~^-l~.n~ Phone(~z) 3~~- ~~v§ Lic.No./~~~ . <br />Mailin Address a ~•r ~f~ C,c_;~. !+~ fGlc <br />Name/Tttle (PI a tLype or print) Signa/t~ure Date <br />J <br />r <br /> <br /> <br />