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FO"" N0' <br />cws-sr <br />tc~a WELL CONSTRUCTION AND TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Office Use on <br />H/ <br /> 1313 r a t Rm 81 Denv CO 80 0 <br /> 1. WELL PERMIT NUMBER a s ~ `1 s ~ <br />2 OWNER NAME(S) s2oec a~ Ccoa~ Co <br /> Mailing Address (1, ,,y 6"10 <br /> City, St. Zip I{=,w c~e~n cc~ `d7163~{ <br /> Phone (970) alb - ~ <br />3. WELL LOCATION AS DRILLED: $ W 1/4 S W 1/4, Sec.. ab Twp. ~ ~_, Range g g W <br /> DISTANCES FROM SEC. L1NES: <br />.~ a s o tt. from 5 o~Sec. line. and 3 O ft. from Gc~Sec, line. OR <br /> SUBDIVISION: LOT_BLOCK FILING(UNIT) <br /> STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION -I S`ID ft. DRILLING METHOD V'o ~ ~.vy ~ W~~~ <br /> DATE COMPLETED _ CI' ~ `~ ' o°I TOTAL DEPTH a9O. ~ ft. DEPTH COMPLETED_a qo. I ft. <br />5. GEOLOGIC LOG: <br />Depth Description of Material (Type, Size, Color, Wla~ter Location) <br />o-a0_ Sot I WE'4~~FVP~UOC-N 6. HOLE DIAM. (in.) From (ft) To (ft) <br />5.6 z S ~ oZ9v • -Z <br />ao- i73 s; It s~otie , stoma to <br />73 --i'7. Co~.l - I.e 1nr~oY <br />~6 -11~ 5: It5~o~.e_ r$I~aIQ <br />~_ 11$° X41 Co, i - 4>4eQ ~ <br />1~I1- aloo SavdLSdoye ~ Si Id S {o.,e ~ ladle. <br />- 7. PLAIN CASING <br />OD (in) Kind Wall Size From(ft) To(ft) <br />3-S ~ RO PUG O.3 " O a) -c <br />aota-aoc,. co~.t - says c•.. <br />_~bg~oZ9'O S0.r,.cQS~er.¢ ~ [; ~d5 or+¢,~ Sl.~ Q <br /> <br /> PERF. CASING: Screen Slot Size: O . o3o't <br /> 3-S ~gD c. o•3't all•Y a o. <br /> <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> <br /> Material _5 i ~ i~ 4 sav,~Q Type ~ <br /> <br />Size 10 -'i0 _ <br /> Irnerval a09 - a9t) Depth <br /> <br /> <br /> 10. GROUTING RECORD: <br /> Material Amount Density Imerval Placement <br />REMARKS: f cndd a dor: .. ( 5 -~ <br />'•~/64 bek~o..:~e. c1,:es ~ ~ •o l ~_ r 90- aoq peav <br />> ~.0-9~*3 ,t 8 ~~p r~- <br />ce-w~ D-@S~i} ^ D-~ <br />1 DISINFECTION: Type h a"e w N' ~oa W e 11 Arm. Used <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemernal Well Test. <br /> TESTING METHOD <br /> Static Level ft. Date/Time measured ,Production Rate gpm, <br /> Pumping level ft. Date~me measured ,Test length (hrs.) <br /> Remarks <br />3. I have read the statements made herein and know the conterrcs thereof, and that they are true to my knowledge. [Pursuant to Section 24-4-1 U4 (13) (a) <br />C.R.S., the making of false statements herein constitutes perjury in the sernnd degree and is punishable es a class 1 misdemeanor.) <br />CONTRACTOR L,/c,i ~u,~ ~,,.ar•~^ ~~~~I I•'^~t__ Phone (sue') 3~a b~4: Lic. No. ~t''~~' <br />Mailin Address ~?,,. %f•: 7S'~~ C,~~-.~° Pc, gr~ rc <br />' <br />Namelfitle (/P~leasye type or print) Signature Date <br />I~p :t Ys.t iC~_ ~ ~ l~cL.--c~:~ <br />r <br /> <br />J <br />~t~t~~~!~~'.I d. `J ~. '-~~ <br />f <br />