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Haldorson 9703236851 p.6 <br />~p ~~J.1 I~~Y ~ f~"Vf~~ <br />STATE OF COI.ORADD, OFRCE OF THE STATE B~INEER ~IX ~(R'.! LACY OO~. .. . <br />,. waL err as y to7 8 <br />L WNERNAME(by H+Idorson Gnu SohS Tie. <br />Matting Address P. o . A ox Io 19. <br />P e . Rl ~{ A,a. <br />Cdy. 61. Zip /ll,t .., /re er , <br /> / <br />Phone { 9 0) 3 - S <br />a vYEtL LOCAT70N As DT>:s ~ ~: ~J `tra 1lf ~11a s~ ~'~ Twp.~/~_ A/ .Rance r O w <br />dISTANC6S FROM 9EC. L/'fE3: <br />!way tt tram . / sec tma and ~ a ~ 4 it trap E~S3ec. tirre. OR <br />Sl)BDN161DN: LOT BLOCK FtlJNG(UNIT) <br />3TAi~' ADDR~53 AT Wp1 LOCATIOC'L- <br />4. GROUND 6UAFACE ELEVATION $ DR9tAVG METHOD 1'~%•- Re /~ ra_ <br />OATS ODMPL.ETED 1- i 3 - 0 4 .TOTAL DEPTH (n'/ • R DEPTH COMPLETED o ` h. <br />S CiEOLOOIC LAt3: <br />GegA fk~nption d Almedd (rypR ~, Cofo, YWder lacmaed & HOLE DIAM. (m) From pg To (b) <br />8 '' O 3. S ` <br />/~ •• 3. S <br />-a•s' <br /> <br />' 7. PLAiN CASWG <br /> OD (at) IGnd WaH Size from([[) To((t) <br />S7'- GSA' ~/l .~~ al,uJe_- SSIi ~•• j$~ee.! ,! fi /.5I.5 - <br /> <br /> <br />1 <br /> PERF. CASWG: Screen SIoI SFze_ . 03 a <br /> ~•' FVG .150 11' <br /> <br /> <br /> <br /> ' <br /> a FILTER PACK: 9. PACI~A PtAC[ <br />MENT: <br /> Material Pen a ia~~ l Type <br /> 6® 3/~ <br /> llgelVal O• Depth <br /> <br /> 1'O. GROUTTIG RECORD: <br /> Material Amaan Density Inlervel Placemerrt <br />RFMARK6: it - ver c Cewnovfl' ~•Sbts 596/ OFe7 ~~. r.r~/ <br /> <br />1 DISNFECTION: Type N1N - (i57o Amt Used /oo ppp~ uSCQ .n d~.'ll,~ fw.r <br /> 1, I~F,.LL ~ DATA: Check Gott fi Test Data LS subnutted on Form Na GWS 39 Supplemertial WeU Test <br />TESTING 1~T1'IDD 14i r - //~ . <br />StaticLawl y4, 1L DaoelTYne measrredJ- I3-oY J~'rs im. Production Rate r1~o aom. <br />Pwnpinp lei /.e' R Datoe/Ra~e mees~rted r -r7-e4 r~ : ~s r. r.,. Test IEttgU (ttrs.) '/i <br />RYrilefk8 / ^' <br />3 l 1~ tydMr Mt~w~ tIW~lwee~ ak blew. tl» oatowme ewaor, aW 7hetlhy aistrue m my IotowNdga. lPu°°a,rt ro Sadian 2441D0 P3) <br />GRS.. Lw rryddep d iWt dt~ I~im aoeAYOs pwp,ry it lte waond dpros ~,d : puisba6k m a dme t mddameenec) <br />CONTRACTOR GJ.%B ~.s1L .-.%4,~-,~, ~ /~,~o ~irr~, Phone (f'7e } fI56 -L SB3 Lic. Na /3P5I. <br />. 0. • I <br />Namelidle (Please hPe a Prim) <br />•7! D. k!:r~cr ~P.-rs.d~*~ <br />/.~ l~-` Date <br />r-ezr-v`~ <br /> <br /> <br />