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"'""'° WELL CONSTRUCTION ANU TEST REPORT <br />aMS.al <br />. }~* Sl'A1 E OF COLOtiAUO, OFFICE OF 7h1E STATE ENt31NEER <br />t. -WELL PERM11' NUMDCR M H - 3558 z. (.K~~-~~ <br />~, <br />)WNER NAME(S) /-/ <br />MaIW>(J Address See <br />cny, st. zlp __F ~., ~ <br />Plwrre (7/11 -1 R.<.- <br />0 <br />Fm Ollloe Uae w.ly <br />3. WELL LOCA710_ 1~9y-D 1~1LLED 51/4 ~/E 1/4, 9ec.~ TwP.~ S .Range G 9 l_,.i <br />DlBTANCEB FROM 8EC. I.lNEB: IZ.oo <br />I~ Zoo IL from ~ ermm Sec. line. and (t. from ~ >'s~ Sec. line. OR <br />SUBDIVISION: LOT BLOCK _ FIUNO(UNIT)_ <br />4.I dROUND SURFACE ELEVATION 2 /. fl. <br />DRIWNQ METHOD a 1Y - Ye'('aY~I <br />DATE COMPLETED $ ~ 21- 4 B <br />TOTAL DEPTH / ~O IL DEPTH <br />5. QEOLOOIC LOQ: <br />Depllr Ueswlptloa of Maledol (iype, 6'ke, Color, Water Looetlon) <br />1 A..l~~• l:.~-.t._s ...! AO ups.. ~Clbl <br />A1eNQ- <br />11 <br />e. HOLE DIAM. pn.) From (ll) <br />~ D <br />7. PLAIN CASINO <br />OD pr>) Kind Wall Slze <br />To (tl) <br />!p0 <br />FrompQ Toff <br />PERF. CASINO: Screen SIoo~~Slze: o.olo ;.,. <br />.~~ /L eel. ~{v ~, <br />8 FILTER PACK: <br />Meledel Si~~ca ,aNd <br />Slae /e-1~ <br />Interval ' Iz•S - f oo' <br />10. . t;IROUTINO RECORD: <br />Material anount Density <br />..~ /D~ sl-1. <br />9. PACKER PLACEMENT <br />Type <br />Ilrierval Placement <br />L_I1.S• .~. e <br />O-/D~ y <br />t I)_YE,,'L TEST DATA: U Check box 6 Test Data Is submRted on Form No. CiWS 39 Supplemental Well Test <br />• TESTINQ METHOD NA <br />SlaUo Lein 7.31 IL Dalelilnle measured 9-//- 9A .Production Rate stpm. <br />Pumpktg level JL Date/Tlme measured. .Test length pus.) <br />Aorrmr4e ~ .. <br />3, 1 hsn road eu sldsmads mods hash and Inapr lM ooMsMs Ilrsnol, and that they lua inn is my krrovdedps. (Pursuant l0 8sslbn 24.4•IW (13)(~ <br />' C.R6. Yn msklnp of l1 }s shdemads hash soneWulss psr)tny In tlrs sscwd daptu and b purdshsbls n a class 1 misdemaensr.J <br />CONTRACTOR fc~e..,.ra~ Geo3CJYAfC4a ~"NC _ ,Phone. 7/ 63S-ozZ9 Uc. No. <br />Natne/Tille (Please type or print) Signature ' ' '' I Date <br />,,.~ -z . -. ~ / . . <br />