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~` <br />~~i°~ WELL CONSTRUCTION AND TEST REPORT <br />169: , tJ~ STAi'E OF COLORADO, OFFICE OF THE <br />'~ 1313 Sherman St.. Rm 818. Darner. ~~I'~r~ll~l~'~~I'll <br />i. WELL PERMIT NUMBER G U l-1 ta) - l z B -50 For Office use ony <br />2 <br />r.o ~r Gold. 1`1:n~„g Co. <br />OWNER NAME(S) C - p~~ Creed, ~' y ic, \ <br />Mailing Address P. d~ goX I q 1 <br />City, St. Zip . c o 6 <br />Phone (719) 6 B9 - O S' <br />3. WELL LOCATION AS DRILLED: ~E 1/4 ,ULJ 1/4,Sec.1ZTwp.~_~_,Range 69 C,J . <br />DISTANCES FROM SEC. LINES: <br />ft. from Sec. line. and ft. from Sec. line. OR <br />SUBDMSION: LOT_ BLOCK FILING(UNT~ <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION /O, y/a5%Stt. DRIWNGMETHOD G~nycn},~ono.~ Air HQr..r~-+er <br />DATE COMPLETED I z /7 zoao .TOTAL DEPTH SO ft. DEPTH COMPLETED SD ft. <br />5. GEOLOGIC LOG: <br /> <br />Depth Desedption of Material (Type, Sqe, Color, Water Location) 6. HOLE DIAM. (n.) From (ft) To (ft) <br />n <br />$ ~ `SU <br />See Albo~c ~ <br /> <br /> 7. PLAIN CASING <br /> _ <br />OD (n) IGnd Wall Size From(ft) To(ft) <br /> R rr S~ce,) O zo <br /> yr, pVG Sc~ ND ~ <br />_ 30 <br /> , <br /> <br /> PERF. CASING: Screen Slot Size: <br /> PVG , O 3Q o <br />~ <br /> _ <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> 1 <br />Material Si 1 ~ ~ So.nd Type <br /> Size <br /> Interval 2.5 - SO Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material Am_ ourn Density Interval Placement <br />REMARKS: ~}°" <br />o-Z.S <br />y°`S, <br />° <br />+ <br /> "' <br />~ <br />Y <br />' <br /> <br />1 DISINFECTION: Type None) ArrtL Used <br /> WELL TEST DATA: ^ Check box 'tf Test Data is submitted on Fonn No. GWS 39 Supplemental Well Test, <br />TESTING METHOD <br />Static Level ft. Date~me measured ,Production Rate gpm. <br />Pumping lave[ ft Date~me measured ,Test length (hrs.) <br />Remarks <br />3. I have read the statamenb made herein and know the eomenb thereof, and that they are true to my knowledge. [Purcuant to Section 24.4104 (13)(a) <br />C.AS., the making o} false stffiamenb herein eonatRutes perjury in the second degree and is punishable ea a class 1 m'radameanor.] <br />CONTRACTOR R K Dr: l~;na Phone _~ Lic. No, <br />Mailin Address .O [30 / oH, so hIT 597 8 <br />Name/Trtle (Pleaseyp$ or prim) <br />SC.O~+ A , Lew ~S/ ['rlar~o.~P:r~ ~ r~J , <br />R airs C~4 V Signature ~ Dateyl %/ <br />7 YO <br /> <br />