2008-08-21_REVISION - M1978091UG

• Permit No: M1978091UG
• IBM Index Class Name: REVISION
• Doc Date: 8/21/2008
• Doc Name: Amendment application
• From: Gault Group Inc.
• To: DRMS
• Type & Sequence: AM3
• Email Name: RCO
• Media Type: D
• Archive: No

FORM NO.
GWS-31
04/2005 WELL CONSTRUCTION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 818, Denver, CO 80203
Phone - Info [phone] Main [phone]
Fax [phone] hftp://www.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: MH - 47845
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: GAULT GROUP INC
MAILING ADDRESS: 36 W MAIN ST
CITY: CORTEZ STATE: CO ZIP CODE: 81321
TELEPHONE NUMBER: 970 409-9591
3. WELL LOCATION AS DRILLED: NE1/4, NE1/4, Sec. 10, Twp. 43 ® N or ? S, Range 4 ? E or ® W
DISTANCES FROM SEC. LINES: ft. from ? N or ? S section line and ft. from ? E or ? W section line.
SUBDIVISION: , LOT , BLOCK , FILING (UNIT)
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: R
must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting:
STREET ADDRESS AT WELL LOCATION: Northin :
4. GROUND SURFACE ELEVATION 10,500 feet DRILLING METHOD AIR ROTARY
DATE COMPLETED 7/8/08 TOTAL DEPTH 120 feet DEPTH COMPLETED 115 feet
5. GEOLOGIC LOG: 6. HOLE DIAM (in.) From ft To ft
Depth Type Grain Size Color Water Loc. 6 3/4 0 120
0-25 TAILINGS/MUCK PALE-MED
GRAY
BROWN 7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
25-120 SAND/ARGYLE RED/ 23/8 PVC 3/16 +2 90
PEBBLE ORANGE

95-105
PERFORATED CASING: Screen Slot Size (in):
23/8 PVC 3/16 90 115

8. FILTER PACK: 9. PACKER PLACEMENT:
Material SILICA SAN Type
Size 10-20
Interval 90-115 Depth
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: ben.pel 350lbs dry 50-90 poured
ben. ch 900 Ibs dry 6-50 poured
cement 2 bas 6-1 0-6 poured
11. DISINFECTION: Type Amt. Used
12. WELL TEST DATA: ? Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD AIR
Static Level 51 ft. Date/Time measured: 7/8/08 Production Rate EST.3 gpm.
Pumping Level ft. Date/Time measured Test Length (hrs) 1/3
Remarks: THIS WELL HAS A 4" X 5" STEEL LOCKING COVER
13. 1 have read the statements made herein and know the contents thereof, and they are true to my knowledge. This document is signed and certified in
accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402-2. [The filing of a document that contains false statements is a violation of
section 37-91-108 1 e , C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license.
Company Name:
WILLIAMS DRILLING CO Phone:
[phone] License Number:
648
Mailing Address: 214 WEST DENVER AVE GUNNISON CO 81230
Signature: Print Name and Title
PIFRANKLIN L ROPER / VICE PRESIDENT Date
8/6/2008