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<br />~°'~" "° <br />cws-ai <br />raroa _ _ <br />WELL CONSTRUCTION AND TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />131 r a Rm8 D v r C080 03 -- <br />For OHice Use onl <br />y <br /> i. WELL PERMfT NUMBER d2 5 S <br />2 OWNER NAME(S) S E' lne ~ q ~oca I Cc~ <br />Mailing Atldress O <br />Clry, St. Zlp N44 CC.7 ~ l63 <br /> Phone ( 70) ~ 6- ~70-I <br />3. WELL LOCATION AS DRILLED: $(.J 1/4 .St+> 1/4, Sec. ~ ~ Twp._~_~_, Range 8rd GJ <br />DISTANCES FROM SEC. LINES: <br />I I cf O ft. from .So~Sec. line. and 3 0 ft. from Sec. line. OR <br />SUBDIVISION: LOT BLOCK FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION ~ 5c(O ft. DRILLING METHOD V'd d 4tAc( ~ w wd~ <br />DATE COMPLETED ~1- (-T' O ~I .TOTAL DEPTH aq•~ ft. DEPTH COMPLETED I~.q• 3 ft. <br />5. GEOLOGIC LUG: <br />Depth Description of Material (Type, Size, Color, WIe,ter Location) <br />O-ao so:l I f..~e4d4er.od~ IroclA S. HOLE ~IAb". (;n.) Frcm (ty Tc (ft) <br />S • 6 ~ 5 O t a 4 <br />.e t CI.... 2 <br />c~-8o 5ildct{o~ <br />I <br />~o-t3 <br />Cowl - h~1ti1.aD <br />_ <br />$3- 1'.14 S.Id S~lese ~ 5~ IQ 7. PLAIN CASING <br />OD (in) Kind Wall S¢e From(ft) To(fi) <br /> 3 • S 'k$O C. o ~ O O. <br /> <br /> <br /> <br /> PERF. CASING: Screen Slot Size: t'~,O 34 n <br /> 3~ ~ o U c O.3 yo•g 1a9.3 <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK: (~ 9. PACKER PLACEMENT: <br /> Material S; ~ ica Sa~.sJ(, Type <br /> Size lo-~.o <br /> Interval I'[•S-la9•`I Depth <br /> <br /> t0. GROUTING RECORD: <br /> Material Amount Density irrtervai Plsce„-,aid <br />' <br />REMARKS: <br />3 er.~e•.:~e et,: S Q~}3 NR •$5-19.5 ee.v <br />'a-? <br /> _ <br />Cer.«e.~~ O• Ott3 ~~ -$.S •~ <br />1 DISINFECTION: Type 1n.or.. I.KOh.~ov We~~ Amt. Used <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level ft. Date/Time measured ,Production Rate gpm. <br />Pumping level ft. Date~me measured , Tes[ length (hrs.) <br />Remarks <br />3. I have read the statements made herein and know the contents thereof, and that they are Vue to my knowledge. [Pursuant to Section 244104 (13) (a) <br />C.R.S., the making of false/~~~tttaaattteme~n]ts herein constitut~e/s perju7 in the second degree and is punishable es a class 1 misdemeanor.] <br />CONTRACTOR ~lJ' 'p~^ /~ ~E~"~ ^ // ~~('~'+ Phone ~7~= ,~~G ~6Yf Lic. No. /2~3 . <br />Mailin Address •v• ~.~ 73%' ~;~~,r [;, `l'td ~~ <br />Name/Thle (Please type or print) Signature Date <br /> <br />. <br />'' ~(~ ~ <br />