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r""MN0' <br />meat <br />. ~av+ WL"U.. CONSTRUC'f10N AND TEST REPOfif <br /> <br />81'ATE OF COLORADO, OFFICE OF TFIE STATE ENGINEER rot oUko use onl <br />Y <br />1. WELL PEIIM(1' NUM <br />DC-fi /N 1l - 355e z. Cn1 r.i' -5) <br />2 ,, / <br />OWNEA NAME(S) /-io~nx.x ~/ac, <br />Malpng Address eo Co ~/ .. 20 <br />Chy, 3l. Zip F eyauce CO ~3 /Z2(o <br />Phone( /9) 7Srf- ' 2S • <br />3. WELL ~OCAl1pN /~.9 DRILLED SE 1/q .S E i/q, Sec. ! 7 Twp. / 9 5 , Nange G 9 1~,~ <br />DISTANCES FROM SEC. LINES: <br />~ o0 11. from _~ .~~~Sec. line. and /oo I(. from ~ s Sea line. OR <br />8UBDM810N: LOT BLOCI( _ FIUNQ(UNIT)__ <br />STREET ADDRESB AT WELL LOCATION: <br />q. GROUND SURFACE ELEVATION 5 Il. DPoWNO METHOD ca 1 r` - Y'o~'ta-Y~/ <br />DATE COMPLETED 8- 20 - 9 g .TOTAL DEPTH / 2 o IL DEPTH COMPLETED / 07 11 <br />5. GEOLOGIC LOO: <br />DopUr ueacriprion of klalarid (type, 6ize, Color, Wdar LoaaUor4 0. HOLE DIAM. (fn.) Frum (Il) To (II) <br />13 0 _[ Zo <br />o- So' ~.Qr..v s aey L:...eefeNe <br />~~ <br />~- So- 70' ~; s r.~~ ,:ve- ar+.~:..sL 7. PLAIN CASINO <br />c w -~ .s+.+ fa.J< OD (kl) Kind Wall Size From(It) Toff <br /> <br />/I..aQn/'o NC W~ /v ~ PVC ~r ~o IOZ (O~ <br />.T4V Sj nwfC IN X45 ~~ <br /> <br /> PEHF. CA31NQ: Screen SIo~ 31ze: o. oro •,,. <br /> f PVC sc%, rfy ~7 _ /c <br /> <br /> <br /> <br /> <br /> 8 FILTER PACK: 9. PACKER PLACEMENT <br /> / <br />Materiel S r I ita Jap16 Type <br /> Size /0^20 <br /> kdenral ' 2 4 - r Z.o DepUr <br /> <br /> i0. . QROUTINa RECORD: <br /> Material Arrwurd Density hrierval Placement <br />REMARKS: so~:al ~;.'f~` ~ ISM t5_2~/• 1..I <br /> <br /> <br />it DISINFECTION: T /1)oNe. AmL Used <br /> <br />• EL ET . TS DATA: ^ Check box p Test De(a Is submkted on Form No. (iWS 39 Supplemental Web Tesl, <br />TESTING METHOD NA <br /> Stetlc Level r.2. fo I IL Date/Tkrle measuued 9-//- 4R . ProdlxUial Rate npm. <br />Pumping level R DatelTbtra measured .Test length Qus.) <br />Remarks ~ . <br />3. 1 hew tad tlrs ehdemenb made herein end know 9a ooniade Brsnoi, and Brd Brsy ue kw to my krrwdedge. (purwenl to BseUon 244104 (1~(i <br />C.H.B., Ere meking of ( a shdemenb herein aoneUtula perjury ti tlb secerd degree and E pradehebb es a class 1 misdemeanor.) <br />CONTRACTOR ,.. ~ G eo ~ c; ca. rNa ~ Pttwre, 7 ~ ro~S - o Z2`~ Lic. No. <br />.., <br />/7.a,..e va. 'C er o ~ r,a Co 090 <br />Name/TMIe (Please type or print) Signature ~ Date <br />