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<br /> <br />;,'„~ ; "' <br />. }~+ <br />:' W[LL CONS'I~UCTION AND TEST REPORT <br />SI'Al E OF COLORADO, OFFICE OF TFIE STATE ENGINEER Fur om.o us. ony <br />i. WELI. PGRM(i' NUMDCR /N H - 3559 z. (mw-~) <br />2 OWNER NAME(S) /-/o~ivawi .ri.~c. <br />Malting Address 35eo Ce%.-.ode _ N; o . ~ / 20 <br />Clly, Sl. Zlp __Jev~uce~O -~ i3lLL(o <br /> Phone ('7/9) 7 6 ~ 2.S <br />3. <br />~ NfELL LOCA7"ION AS DRILLED S_i!4 ~V 6 1/4, 9ec.~ Twp.~ S .Range 4 >~ 1~.~ <br />019TANCE9 PROM 8EC. LINEB: rzoo <br />2 0 o It. from ~Nmm~ Sec. line. and _~ Il. from ~ y~~~Sec. line. OR <br />SUBDIVISION: LOT BLOCI( _ FILINCi(UNIT)____ <br />STREET ADDRESS AT WELL LOCATION: <br />A. AROUND 8URFACE ELEVATION 2 /. Il. DRIWNQ METHOD a I r - ro To-Y1/ <br />DATE COMPLETED S - ~l - 9 B .TOTAL DEPTH ! ~~ (t DEPTH COMPLETED S 7 Il <br />5. QEOLOOIC LOO: <br />UepUr UesalpUon of Maledsl (Type, Size, Color, Water Loeallor~ & HOLE DIAM. (ln.) From (Il) To (ft) <br />R 0 ! 00 <br /> <br />S l~.a..la iwr .a.r ds <br /> 7. PLAIN CASINO <br /> OD pn) . Khtd Wall Size From(fl) To(p <br /> Pv <br /> c ~.YQ. ~ ~ <br />_~ t <br /> <br /> <br /> PERF. CASINQ: Screen SIo~ Size: o.o/o ;,,, <br /> ~ r"'YC. ~ eel. ya ~.._ <br /> _ <br /> <br /> <br /> <br /> 8 FILTER PACK: 9. PACKER PLACEMENT <br /> Material `Sl~iea JaNd Type <br /> Size /o-2p <br /> kttervel ' i.S - I ~' Depth <br /> <br /> i0. QROlIl1N0 RECORD: <br /> Material /Unount Density interval Placement <br />REMARKS: s;l:d.. ~s..•1 ~ Leo .+ea4 ~°_~s.s, ar+. ~ <br /> <br /> <br /> <br />11 DISINFECTION: T lJoNa- Amt Used <br />t <br />• ILYELS TEST DATA: ^ Check box H Test Data 4R submftted oR Ftxm No. CiWS 39 Supplemental Wep Test. <br />TES7INQ METHOD N A <br />StaUo level 9, 31 It Date/ilme measured 9-//-YS . ProducUolt Rate gpm. <br />Pumptrrg level ft Date/Mre measured ~ .Test lertgth (Ftrs.) <br />Remazks ~ . <br />3. 1 hew reed tlrs alalamants mods harakr and Imow IM oadsrda Uroraal, trod ihd 9Ny en bw b my knowlsdga. (PursusM b SeWbn 24+104 (ta)(r <br />C.RB., M mskhrg d 1 stdemeMs hereto oointiddea par)ury H tlb wcad decree and b punlshabie sa a class 1 mledemaenor.J <br />rCONTRACTOR ~as ~~r . G eo,~r~~uc+t r ~ac _ ~, PhoRe 7 / X35 ^ o z2.'i Uc. No. <br />Name/Tflle (Please Type or print) / ~ Signature J ' ~ ~ Dale <br />~,..~ ~ ~. <br />