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WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />WELL PERMff NUMBER <br />OWNER NAME(S) <br />Mailing Address <br />City, St. Zlp <br />Phone f 303 1 <br />C~Oo G°p~ <br />3. WELL LOCATION AS DRILLED: NW 1/4 SE 1/4, Sec. 27 Twp. 1 N ,Range 52 W <br />DISTANCES FROM SEC. LINES: <br />1440 k. from south Sec. Ilne. and 2007 R. from east Sec. line. OR <br />(nOrlh ar ~oulh) Irrul d wwa) <br />SUBDIVISION: LOT_ BLOCK FILING(UNf1) <br />STREET ADDRESS AT WELL LOCATION: <br />GROUND SURFACE ELEVATION <br />DATE COMPLETED <br />k. DRILLING ME7H00 <br />TOTAL DEPTH 159 R. DEPTH <br />5. GEOLOGIC LOG: <br />0.om 0.wripdon or Mrrbr7d (iyq, 91n, Color. W~tw Locrtlen) <br />0-1 loam <br />1-14 clay,sand <br />14-65'~ coarse gravel <br />652-69 rocks hard <br />69-72 gravel <br />72-72 rocks <br />72's-117' eravel <br />117'-122`s brule.sorne gravel & sand <br />122'-1'10 coats Pravel <br />1'10-144 gravel h sand <br />144-147' rocks <br />147'-155 brule.ereen <br />155-159 clav.vellow <br />6. HOLE DIAM. (in,) From (tt) To (k) <br />8~; ~- 159 <br /> <br />7. PLAIN CASINO <br />OD (in) Knd Wall Slze From(k) To(k) <br />6 5/8 steel .188 +1 20 <br />5 plastic .20 7 114 <br />-~ plastic .20 120 130 <br />PERF. CASING: Screen Slot Slze: .032 <br />5 elastic .20 114 120 <br />~_ R13;7C1~ -~0 ~_ 1554- <br />8. FILTER PACK: <br />Material Gravel <br />Size Buckshot <br />Interval 20' to 159' <br />10. GROUTING RECORD: <br />9. PACKER PLACEMENT: <br />Type <br />Material Amount Densky Interval Placement <br />REMARKS: rPment "1 sack near 7'rn 7fl' mill rnha <br />DISINFECTION: Type HTH dry powder Amt. Used 1 <br />WELL TEST DATA: <br />TESTING METHOD <br />Static Level 10 <br />Pumping level 11 <br />^ Check box 1f Test Data Is submitted on Supplemental Form. <br />Bailed <br />DateTme <br />Fa Olllca Uw only <br />Production Rat <br />Test length (hr, <br />3. I hrav~ rr.W dN ablemenb mwb hw~ln W Frbw dr conlanb IMno1, W Ihral d,ry r bIM b my Waw4dpra. IPunwnl b 9w.11on 21J-101 (1~(p 0.0.9., Mw m~kM <br />d Ir,lw sWSnrnb hanln ConaUNlw psrlury In dv wooed dagrw rand b punlNraDN o ^ dm I mlWwwugr,l <br />CONTRACTOR Canfield Drillin~('o. Phone (3n7) RF,7-7oL'3 Uc. No.765 <br />Mailing Address P 0. Box 519 Fort Morgan CO. 80701 <br />Name(Title (Please type or print) Signature Date <br />i0 ~ ~/~ ._._. <br />