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"'"""'' WLLL CONS"fRUC'IION ANU lES7 FlEPOfiT <br />eWSJI <br />! ^+ . 81'AlE OF COLOFiADO, OFFICE OF 1'FIE STATE EN(31NEER <br />1. WELL I'[flMfl'NUMDL_ft MH- 35582 l~~w-~ <br />)WNER NAME(S) <br />MaNlirtl Address <br />City. St. Zlp _.~ <br />Phone r-7i91 - <br />m <br />For Ollloo Uw ary <br />1/4 SE 1/A, Sec. /~ TwP.~ 5' . Rnnge G 9 <br />~_ it. Iron se..'T~ Sea line. and 7S0 rt. Irorn east' Sea line. OR <br />-tnarnroraauttq~ -psacorwasq' <br />8UBDIVISION: LOT~BLOCIC _ FIUNQ(UNIT) <br />BTREET ADDRE89 AT WELL LOCATION: <br />AROUND SURFACE ELEVATION _053.5 IL ORILUNI3 METHOD a I r- - ro"1-a.Y•/ <br />DATE COMPLETED 8 - ZZ - 9 $ .TOTAL DEPTH 7o IL DF_P711 COMPLETED <br />0. GEOLOGIC LOG: <br />Uepgr Uaacripllon d Moledol (type, Ske, Color, Waler LoeaUonl <br /> <br />a_ <br />G. HOLE DIAM. (in.) Frum (rt) To (Il) <br />B <br /> <br />7. PLAIN CASING <br />O <br />K4i <br />P Fra D tt) <br />W <br />_ <br />V <br />~ ~~ <br />~ PVC. <br />_ ~z <br />PFJaF. CASINO: Screen <br />~ vc <br />To(ll) <br />tl FILTER PACK: e. PACKER PLACEMENT: <br />Materiel s i ~ iea ad~+d Type <br />Size io-zo <br />10. . GROUTING RECORD: <br />Malerlal /4nount Density Interval Placerrtenl <br />e.. ~_ _sfd. _ o -icr ~• <br />Vf)! ELF j ST DATA: U Ciredc box it Test Data is sutuNtted on Form No. 4WS 39 Supplemental WeU Test. <br />TESTING METFIOD N A <br />StaUl: Level 19.85 IL Date/flme measured 9-//- 9'R .Production Bale <br />Pump4rg level R Date/Tlme measured ~ ' ' .Test length (lus.) <br />3. I hwe Nad UN dUemenU made ImnM and know Ba oonblde Uureol, aml Orel they Ara 4w W my knowledge. (Puraeant to SeeWn 244104 (13)( ' <br />. C.R.B., BN mekln0 ore eldemanb Mrein ooroWMee perjury In Ihs eeernd dapres and M punlsMbls u a clews 1 mkdenwanor.J <br />CONTRACTOR <,,,..ra~ Geo.3ciowac~c . r.~~.. ~ ~_ Phone_ 7/ ro3S'o z29 _ Uc. No. <br />Vame/flUe (Please type or print) ~ I Signature ~ ~ Date <br />