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owrsi~' WELL CONSTRUCTION AND TEST REPORT <br />~a/w STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />~ ~ For rntKe ueo Doty <br /> <br />i <br />~ <br />1. WELL PERMCi NUMBER 11tH - 379!! ~m w- q~ ~i <br />2 OWNER NAME(S) t-ro ('Na..~ + Tr+c. <br />Mailing Address 3500 5-1-~.tes ff;4 w4.v /moo <br />Clty, SL Zip ~lorwc¢~, C o 9/ ~ ' <br /> Phone (7/9) 7B~- /,Z.o <br />3. WELL LOCATION AS DRILLED: 5 E 1/4 N E 1 j4, Sec. 1 7 Twp. l 9 5 ,Range (0 8 w <br />DISTANCES FROM SEC. LINES: <br />f~3foo ft. from Sec. line. and o0 ft, from ~T,Sec. line. OR <br />SUBDIVISION: LOT BLOCK _ FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION S/20 tt. DRILLING METHOD Air ~-~»r...tr <br />DATE COMPLETED ~-/7- oo .TOTAL DEPTH _~ 3 ft. DEPTH COMPLETED ~2 R. <br />5. GEOLOGIC LOG: <br />Depth Description of Material (type, Size, Color, Water Location) 6. HOLE DIAM. (in.) From (it) To (ft) <br />g O ~- <br /> <br /> <br />O - 3 r q re-y s (t~(e a~ 7. PLAIN CASING <br /> OD (in) .Kind Wall Size From(ft) To(ft) <br />3 - 5to' Snntds~'on+C <br />i ~1t re..a.+ !Le -' ~'! PVL $c/.. ~lo~ -~' 3 f <br />~ <br />1'a,..tel uar KryS fo <br />-~--~-~ ~7 Z. <br />. <br />IT~~,'~ a rev co ev ro o r <br />O - ' ~af-~-~ rd • tit G <br />s•~,< PERF. CASING: Screen Slot Size: o. o/0 4 <br /> ~ 'PVG 5~1.• 10 <br /> _ <br /> <br /> ,K gam, ¢O o.lz5" w>(( s~zc <br /> <br /> & FILTER PACK: 9. PACKER PLACEMENTt <br /> Material Colorado $; (,~. Type <br /> Size to - zo <br /> Interval ~'- tF3' Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br />REMARKS: vo..t' 'L~~ y,.•k...'a O _ ~' ~r<s ~+t! <br /> <br /> <br /> d <br />1 DISINFECTION: T e Nor+~ Amt. Use <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemental WeII Test. <br />TESTING METHOD Jl o..ra <br />Static Level yloo (t. Date~me measured 5 ~ oo i ,Production Rate gpm. <br />Pumping level fL Date~me measured Test length (hrs.) <br />Remarks GJa// '~a.lfcl .ZY'-'f8 /(er-rs a rcaoucr af{•e~ r..r <br />3. I have read the statements made herein and know the contents thereof, and that they are true to my knowledge. Pursuant to Seetion 244104 (13) (a) <br />C.IiS., the making of false statements herein constitutes perjury in the second degree end is punishable as a olass 1 misdemeanor.f <br />CONTRACTOR Phone ~~ Lic. No. <br />Mai i Address <br />!N7ame/Titte (Please type!1or print) /. <br />Ko~a(d ~ ~i.r~+GI, fl.~%J. /~'on+s..~>L....r~l Sig / <br />p-y..~rrt~ lam- Datle <br />J ~ 9- <br />