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<br />"'""'"` <br />nee s~ <br />. +~+ <br />~= WELL CONSTRUC~I ION AND 7 EST FlEPORT <br /> <br />STAI E OF COLOMDO, OFFICE OF ThIE STATE EN(31NEER For an~e uae e~ay <br />I. WELL I'Et1Mf1" NUM <br />[ <br />3L=11 /Y1 {/- 3SSe2. ~MW-?~ <br />2 , <br />/ <br />OWNER NAME(S) _ No~iVe. rr+ 1 iJ~. <br />Malting Address 35ea Ce /e,-ode jo ..~.~ <br />cey, st. zy, ._ F a~.,~c Co <br />/ 2 0 <br />~ /L2(o <br /> Phurte(7/9) 78'1- ~ ZS <br />3. WELL OCAItON@S DRILLED SE 1)4 SE 1/A, Sec. ~~ Twp, / `~ S , Ranye ~. a l.r.i <br />OISTANCEe FROM SEC. LINES; <br />9~ IL Irom _i mm r1.e~Sec. line, and 7S0 fl. born ~a s~~8en SSec. line. OR <br />3UBDMSION: LOT BLOCK _ FILINO(UNIT)_ <br />3TREE1' ADDRESS AT WELL LOCA710N: <br />4. gROUND SURFACE ELEVATION $053. ~ Il. DRILUNO METHOp a t r- ' ro'~'4r~/ <br />DATE COMPLETED 8 - 2Z - 9 g .TOTAL DEPTH 70 It DEPTH COMPLETED 5~7 li <br />5. QEOLOCiIC LOO: <br />UopUi tlescilpllon of Motedal (type, Size, Color, Water Location) 6. HOLE DIAM. pn.) from (II) To (11) <br />g o X70 <br />O-IL' f~ rw, iwlG-t rd,,.ree( S4~D'!AM <br /> <br />rz - z5 /f. .r r+. y . ri"e- s ra:e,eL 7. PLAIN CASING <br />e e.u .., saw+ls eNe. OD (In) KUx! Wall Size Fronr(11) Toff <br /> ~C 3~`~ o ! i <br />~ <br />Z ri - ~' s~n.c a.5 .c. o vc . <br />Sf P VL ,~. 4rp ~- <br />~*c <br /> , <br />_ jo -~O .~ o wc' <br />9 y~Y E <br />_ <br />O r PERF. CA31NQ: Screen Slo4Size: o.olo ;N, <br /> ~- 1~ /C. 3 U.. ~° ~- -rL <br /> <br /> <br /> <br /> <br /> 8 FILTER PACK 9. PACKER PLACEMENT <br /> Material Sr~.ea Sans Type <br /> 61ze /°-Z.o <br /> hderval ' - ' Depth <br /> <br /> iQ . OROUTINO RECORD: <br /> Material Amourri Density interval Placement <br />REMARKS: it f:+. 3~a~' . ~r t~o-t~ !° -/ ' awra <br />re.. tar sfd, o-/or ~r <br /> <br />I1 DISINFECTION: T NsN~ Amt. Used <br />1 ~ ZEST DATA: ^ Check boar a Test Data is subm0ted on Form No. GWS 39 Supplemental Well Test <br />TESTING METHOD N R <br /> Static Level 19.85 fi. Dale/time measured 9-//- 98 . Produdwn Rate apm. <br />Prrrrrpkrg level R. Date/Time meastn8d .Test length (hrs.) <br />Remarks <br />13. I hew reed the tlelaments made hereto end Mrrow the aonbrde gtmaol, end Uud tlroy en flue b my knowledge. [Rnsuant to Ssctbn 244104 (1a)p <br />C.RS., Ure meking of ( alalemanls MreN oomUkrles perjury M Uie secmal degree and M punishable m a elaes 1 misdemomar.) <br />.,• ... <br />CONTRACTOR ,.~ ~ o ci cq rec. Phone, 7/ 63S-oZ29 Uc. No. <br />r'/.a...¢ v¢, G er r.++ Co 090 <br />Name/fkie (Please type or prhN) J Signature _ Oate <br />J -. - <br />