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F°"" "° <br />ra 31 WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />3 e nS ~ <br />De v r CO For office use only <br />i. r <br />WELL PERMff NUMBER 3375 <br />2 OWNER NAME(S) Cx:~~ GYezk 4' \{Cc~oC Go)cI I~;hCV,o ~• <br />Mailing Address P.O ~ oX 19/ <br />City, St. Zip yCc~or . Co R6R6D <br /> Phone (-71q) 684 p <br />3. WELL LOCATION AS DRILLED: St>J 1/4_1/4, Sec.~_Twp. /,S S ,Range 69 (.J <br />DISTANCES FROM SEC. LINES: <br />ft. from Sec. line. and ft. from Sec. line. OR <br />~ ~ <br />SUBDMSION: LOT_BLOCK FILING(UNfI) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION ft. DRILLING METHOD Re~exsZ C-~ccy..\o-~~or~ <br />DATE COMPLETED ~o Z 3 `1 P .TOTAL DEPTH Z 70 ft. DEPTH COMPLETED Z 70 ft. <br />5. GEOLOGIC LOG: <br />Depth Description of Material (type, Sae, Color, Water Location) 6. HOLE DIAM. (in.) From (ft) To (ft) <br />1 0 O ~O <br />7,6 3o zzo <br />e~ A~o~.`. ~Ysr zzo z7O <br /> <br /> 7. PLAIN CASING <br /> OD (in) Kind Wall Size From(ft) To(ft) <br /> ~_ p ~c Sc~, 40 ~ Z/O <br /> <br /> <br /> <br /> PERF. CASING: Screen Slot Size: O.oZo <br /> ~ <br />'PUC ~ yo 2!O Z70 <br /> _ <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> 11 <br />Material S~\~~. scxhd Type <br /> Size (D - Zo <br /> Interval zo7.I- Z ~o Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br />REMARKS: Derct;c,,, te.. -~ 170-207 <br />~i, lcc,.,e~ O - / 70 <br /> s <br />1 DISINFECTION: Type N oh ~ Amt <br />. Used <br /> WELL TEST DATA: ^ Check boxrf Test Data is submitted on Fonn No. GWS 39 Supplemental Wel[ Tes[. <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 read the statements made herein and know the corrteMs thereof, and that they are true to my knowledge. [Pursuant to Section 244104 (13) (a) <br />C.R.S., the making of false stetemerrL herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor.] <br />CONTRACTOR ~ K ~~, ~ ~ i ng Phone (-J Lic. No. <br />Mailin Address V <br />Name/Trtle (Please type or print) <br />six, R. t.z,~: M~~ ~ <br />!= - r ~ ors U Signature Date <br />~Z.~~,~ <br />v~ <br />