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fO1M M9' <br />GW571 <br />;ate WELL CONST ION AND TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Ollica Use only <br />1. WELL PERMIT NUMBER /M H - 379!l CrN w- 9~ <br />2 OWNER NAME(S) ~o lva~ ~ 1 wr c . <br />Mailing Address 350o Sto.t~ l4'0 r.+wv / O <br />Ciry, St. Zip ~lprwec~ co g) fa <br /> Phone (7i9) 78 - / o <br />3. WELL LOCATION AS DRILLED: $ E t/4 N E 1/4, Sec. 17 Twp. / 9 5 ,Range to $ lJ <br />DISTANCES FROM SEC. LINES: <br />_/! 3l0o ft. from ~~~TSec. line. and 00 It. from ~~~Sec. line. OR <br />SUBDIVISION: LOT BLOCK FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: - <br />4. GROUND SURFACE ELEVATION S/20 Ii. DRIWNG METFIOD Ai- ~.a»„her <br />DATE COMPLETED 5/-/7- oo .TOTAL DEPTH ~_ft. DEPTH COMPLETED hr.2 ft <br />5. GEOLOGIC LOG: <br />Deptit Description of Malarial (type, Siza, Color, Water location) s. HOLE DIAM. (in.) From (It) jo (ft) <br />f3 ~ rt~3 <br /> <br /> <br />O - 3 ~ w rev <{ta(e ~ 7. PLAIN CASING <br /> OD (in) Kind Wall Size From(ft) To(ft) <br />- Or nNd .vt i t<f ro..au e - ~~ ~VL 5~1,. VDT '(' 3 1 <br />ar.tel bar r o 37 2 <br />r a C a/ ro ~ ~ <br />~O~al¢ r ra . ar C <br />se t'I' P <br />RF. CASING: Screen Slot Size: O. o/o ~ <br />E <br /> ~( <br />~ <br />Scl.• <br />L <br />~ <br /> .. <br />.- <br />_ <br /> <br /> .7C 5~R•rfO i O.IZ$~ wall 3/ZG <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material Colora~. $; /,~ Type <br /> Size yo - zo <br /> Interval S'- ~3' Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material Amount Density Interval Placement <br />REMARKS: ro.~ ; 2~y ~.~x O_~~ ~,.<..I•atl <br /> ~L~ u <br />.. avr <br />J ~ <br />o~5 kS <br />iQ~ <br />~ <br /> __ <br />_ <br />_ <br />- <br />._ <br />7 -T - <br /> <br />1 DISINFECTION: T e /JowQ- Amt. Used <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemental Well Test. <br />TESTING METHOD /Jo.oe.. <br />Static Level ~}/oo ft. Date(Time measured 5 s oo i ,Production Rate gpm. <br />Pumping level ft Date~me measured ,Test length (hrs.) <br />Remarks Gl¢I/ -futeJ Z5F'-4`8 ~«-rs o r<GOvcr a~}~ei ...r <br />3. I have road the etatemanta made herein and know the contents (hereof, and thel they era Uua to my knowledge. Pursuant to Section 24-4.104 (13)(a <br />C.RS., the making al false elatemants herein consGlulae perjury In the second degree and la punishable as a class 1 misdemeanor.) <br />CONTRACTOR Phone LJ Lic. No. <br />ai i Addr ss <br />!N~ame/Title (Please type!1or print) ,/- <br />Ko~Ja~~ ~. ~rn.rCr M1.~. /eoNSr~f...u~{ Sig Dn / <br />p-y.~..is~ 1~.~-~-~-- Date q <br />J ~ r - Oo <br />