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FOR1N0. <br />~o~t WELL CONSTRUCTION ANO TEST REPORT <br />STATE OF CO[ARADO, OFFICE OF THE STATE ENGINEER Fa<our~a trso only <br /> <br />y. <br />WELL PERMf i NUMBER M M- 3 Sit S 4 C P 3L •, <br />~"~ <br />2 OWNER NAME(S) f/o~,ya..~r Tae. <br />Melling AddfeSS 5~ a i ,.~a. /20 <br />City, St Zip Flo+o~+~e. co 8/z a <br />Phone (T/y) 7g~-tor 2S <br />a WELL LOCATION AS DRILLED: s E y/4 sE 1/4, Sec. 17 Twp.~_ ~, Range t'o $ ~ <br />DISTANCES FROM SEC. ONES: <br />moo ft. from So»'f~ Sea Une. and ZSo ft from G45t Sec. line. OR <br />~' - <br />SUBDIVISION: LOT BLOCK FIUNG(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION $O(o0 ft: DRIWNG METHOD air - Yo'~'ar)/ <br />DATE COMPLETED /o - f z - oo .TOTAL DEPTH ~~ ft. DEPTH COMPLETED 37 ft. <br />S GEOLOGIC LOG: <br />DapM Description of Material (Type, Sae, Cobb Water Location) 6. HOLE DIAM. (n.) From (ft) To (ft) <br />(v O 'f(r - <br />O- ~3 S+wds Li~wc~1'o.+e r. »~F <br /> <br />~3 -.,r` SG.../e - a rdv 7. PLAIN CASING <br /> OD (in) Kind WaU Size From(ft) To(ft) <br /> !.S I VG scl,.go ~_ i <br /> <br /> <br /> <br /> PERF. CASING: Screen Slot Size: J6 " d r: 111 <br /> <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACFJdENT: <br /> Material Si/ice Sa..+d Type <br /> Size /o x 20 <br /> Interval Zz' - sr~ ~ Depth <br /> <br /> y0. GROUTING RECORD: <br /> Material Amount Density Imerval Placement <br />REMARKS: ieze.,. ~ / or t,a.. r s.+titan'~'ft 4 7t~l~~i~%/~, 22' m..r <br /> <br />1 DISINFECTION: Type Arttt. Used <br /> WEL. TEST DATA: ^ Check box if Test Data is submitted on Fonn No. GWS 39 Supplememal WeU Test <br />TESTING T~El1-IOD e..c <br />Static Level. 27.4 tL Date/Time measured ~ ~ eo -° R.v Prodtxxiort Rate --' apm. <br />Pumping level ft. Date/time measured .Test length (hrs.) <br />Remarks <br />3. I havo read the atatamems made herein and know the canertls thereof. and Mat they are true to my knowledge. [Pursuant to Section 244104 lt~l~ <br />aR.S., Ma making of idea statements herein constituttes perjury in the second degree and is punisturWa a6 a class 1 misdemeanor) <br />CONTRACTOR Phone (_~ Ua No. <br />Maifin Address <br />NamelTNe (Please type or prim) Signatyre~ Date <br />