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f° NO• WELL CONSTRUCTION AND TEST_FIEP1]RT <br />roivat • STATE OF COLORADO, OFFICE C ~~I IIIIIIIIIIIII III R <br />e <br />1. WELL PERMff NUMBER G V M W - /zA - 300 For orfine uge ony <br />2 OWNER NAME(S) Grip p~~ Cxer~t ~' 1JTc,~cr Ga)cl (`~;~,;~ ~p, <br />Mailing Address -P~.' P,rx r 41 <br />GO !f o $G D <br />City, St. Zip J ~ ctor <br /> ~ <br />Phone (719) 689 - +fp <br />3. WELL LOCATION AS DRILLED: ~_t/4 lug 1/4, Sec,1Z Twp. /,S ~_, Range 6'9 ~_ <br />DISTANCES FROM SEC. LINES: <br />n from Sec. line. and ft. from Sec. line. OR <br />'T+i 4' <br />SUBDMSION: LOT BLOCK FILJNG(UNfI) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION /O O~S,6 ft. DRIWNG METHOD Cov~J ¢,ti~,~ono.1 Air ~~~t+vr`car <br />DATE COMPLETED z / z zct~o .TOTAL DEPTH 300 ft. DEPTH COMPLETED 300 ft. <br />5. GEOLOGIC LOG: <br />Depth Dncription oT Material (type, Sae, Color, Water Location) & HOLE DIAM. (in.) From (ft) To (ft) <br />$ ~ 3~0 <br /> <br /> <br /> 7. PLAIN CASING <br /> OD (n) Kind Wall Size From(ft) To(ft) <br /> 8" ,S~~e.\ D O <br /> YG S~ O Z~ <br /> <br /> <br /> PERF. CASING: Screen Slot Size: <br /> p~+c sal. Zoo Sao <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> 1 <br />Material Si 1 ~ cc- Saud Type <br /> Size <br /> Irnerval / 80 - 30 Depth <br /> <br /> 10. GROUTING RECORD: <br /> Mazerial Amount Density Interval Placement <br />REMARKS: den~or„-1C, 5{µnn~O`° D-/SO <br /> <br />1 DISINFECTION: Type N~re~ Arrn Used <br /> WELL TEST DATA: ^ Check box 'tf Test Data is submitted on Form No. GWS 39 Supplemernal Well Test. <br />TESTING METHOD <br />Static Level ft. Date~me measured ,Production Rate gpm. <br />Pumping level ft. Date~me measured ,Test length (hrs.) <br />Remarks <br />3. I have reed tite statemanb made herein and know the eontenb thereof, and that they ere true to my knowledge. [Pursuant to Section 244104 (13) (a) <br />C.rLS., the making of }else statemerrb herein constitutes perjury in the second degree and is punishable es a class 1 misdemeanor.] <br />CONTRACTOR ~ K ~r ~) ~ ~ ha Phone L_~ Lic. No. <br />Mailin Address O• }~4 Rams M?' ,$ 758 <br />Name/Tdle (Please type or print) <br />Scott i=1. L¢„~~s/ Mc.r~ eN~ Erv , <br />air ~~ V Signature ~%GV ~ Date V <br /> <br />