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<br />rae"1"° WELL CONSTRUC7t/_"'-' - REPORT <br />-_~ <br />tors. 'STATE OFS OLORASO,'ll'I11111I""I'Iv ENGINEER <br />1. WELL PERMff NUMBER G U M W - 11 A - SDO For Office use ony <br />2 OWNER NAME(S) 1- r: o P~~ Cr ee~C `~ ~ ic,~r Gola h1;f.;l,a Co. <br />Mailing Address P,O. cox 19/ <br />City, St. Zip \I;c~;or Co So8G0 <br /> Phone (714) 6 8y -i4o~'~ <br />3. WELL LOCATION AS DRILLED: SE 1/4 ~1 t,J 1/4, Sec. (7 Twp. /S _ 5 ,Range 6 9 W <br />DISTANCES FROM SEC. LINES: <br />ft. from Sec, line. and ft. from Sec. line. OR <br />SUBDNISION: LOT_BLOCK FILING(UNII) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION o 2 7$ ft. DRILLING METHOD C~nJer.~~or~o-1 -' ABC No.~.t.,e,r <br />DATE COMPLETED lz~/S~zooo .TOTAL DEPTH Soo ft. DEPIIi COMPLETED Soo ft. <br />5. GEOLOGIC LOG: <br />Depth Description of Material (Type, Size, Color, Water Location) 6. HOLE DIAM. (in.) From (ft) To (ft) <br />g o SGYJ <br /><r. e F\ ~a c <br /> <br /> 7. PLAIN CASING <br /> OD (in) Kind Wall Size From(ft) To(ft) <br /> S~' S~~1 o zo <br /> ~" PbG ~~ o SLoo <br /> <br /> <br /> PERF. CASING: Screen Slot Size: <br /> ~~ U~ ~ ~ m <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material S~ 1; ~ SQ„d Type <br /> Size <br /> Imerval ,~y7p-,Soo Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material Amoum Density Imerval Placement <br />REMARKS: ~n\~..;{~,~ D 380 <br /> <br />1 DISINFECTION: Type None, Amt. Used <br /> WELL TEST DATA: ^ Check box rf Test Data is submitted on Fonn No. GWS 39 Supplemental Well Test. <br />TESTING MEIT~OD <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 read the statemerns made herein and know the contents thereof, and that they are true to my knowledge. [Pursuant to Section 24-0-104 (13)(a) <br />C.R.S., the mekinp of false statements herein constitutes perjury in the second degree end v5 punishable as a class 1 misdemeanor.] <br />CONTRACTOR r: ~ ~ h Phone (_~ Lic. No. <br />Mailin Address o l04 a <br />Name/Trtle (P ease type or prim) <br />sett R • ~e~;~ rra ce~v' E ,.~. A~~~ Signature Date <br />3 ' D I <br />