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~~. «a <br />~~~ <br />~~ WELL CONSTRUCTION ANQ TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For orrwo Uae enM <br />1. WELL PERMff NUMBER N~( Cvz) ~'~' <br />2 OWNER NAME(S) Ho Iwsn. -~ ..a. <br />MaiUngAddress 35DO Sf..t-e ~;w ..,..~ Ito <br />City, SL Zip F(erar•.c~ co sr <br /> Phone (719) 6 tf - lS <br />3 WELL LOCATION AS DRILLED: 5 ca 1!4 -~ 6 1/4, Sec. I Z Twp.~9 _ S ,Range fo ~ lJ <br />pISTANCES FROM SEC. UNES: <br />a`oo ft, frpm Ner'I'~. Sea line. and i5ao ft. From eo.s~" Sec. Une. OR <br />-trtargrarsaautnT -'lamrarwesq' <br />SUBDIVISION: LOT BLOCK FIUNG(UNFT) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION 076 ft. DRIWNG METHOD G<ir Y'o'h+.rSF <br />DATE COMPLETED 531-00 .TOTAL DEPTH 39-.! ft. DEPTH COMPLETED 36./ fL <br />S GEOLOGIC LOG: <br />Depth Description of Material (Type, Size, Color, Water location) f% HOLE DL4M. (tn.) From (ft) To (ft) <br />to O X9.5 <br />O - Sy.S S.a.d3j'n.+c . . a/a/ a /t: rwN <br /> <br /> 7. PLAIN CASING <br /> OD (in) IGnd Way Size From(ft) To(ft) <br /> <br /> <br /> <br /> <br /> PEAF. CASING: Screen Slot Size: ./ ~~ c/.'!/s <br /> /.S ~~ sa• No 31.1 3~. <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK 9. PACKER PLACEMENT: <br /> Material 3. I ~ ~. 5»d Type <br /> Size 8 tc tL <br /> Imerval zl - 39,5' Depth <br /> <br /> 10. GROUTING RECORD: ' <br /> eria <br />Amount Density Interval . Placement <br />Ma <br />t <br />l <br />REMARKS: a ...s r a.~ W r e <br />e~v + <br />~- <br />~ <br />' <br />` <br />~y (v 6 e.~i' ~~Zf~ <br />gYd.:l' ~ .1 0 -3 Ro..~r <br /> / <br />1 DISINFECTION: Type Amt Used <br /> WELL TE DATA: ^ Check box 'd Test Dana is submitted txt Fonn Na GWS 39 Supplemental WeU Tt~t. . <br />TESTING METHOD ~oNC ' <br />Static Level i 5z tt. Datefiune measured G -/ -oo r .~~r Production Rate - 9pm. <br />Pumping level fG Da[e/Tkne measured .Test length (hrs.) <br />Remarks <br />3 1 have read the statements made herein and know the comergs thereof. and that they are true to rrry knowktdge. ]Pursuarrt w SaGion 244.104 pa)(a) <br />C.RS., the making of false sratemems herein constinaos paryury in the soeond degree and is punishable as a class i mrsdetnaanor.] <br />CONTF]ACTOR Phone (_) Uc. No. <br />Mailin Address <br />Name/Trtle (Please type or print) Sign~ttlf~ ~ Date ~_8 _o! <br />