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Sep 21 09 04:56p DOROTHY POLEN 970-824-6211 P.2 <br />FORM No_ <br />GW5-31 <br />04/2005 WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St., Room 818, Denver, CO 80203 <br />Phone - Info (303) 866-3587 Main (303) 866-3581 <br />Fax 303 866-3589 http://www.water.state-co,us For Office Use Only <br />1. WELL PERMIT NUMBER: -a ?f <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: ?p LL <br />MAILING ADDRESS: , /110. 0 Lj " <br />CITY: E STATE: O ZIP CODE: / d 9 <br />TELEPHONE NUMBER: '1170) 76- ..$? ? <br />3. WELL LOCATION AS DRILLED: FLU 114, __'114, Sec. ?l 0, Twp. -/6- ® Nor F S, Range }? j ? E or,® W <br />DISTANCES FROM SEC. LINES: ft. from ? N or ® S section line and 4/ ? 9 ft, from ® E or ? W section line. <br />SUBDIVISION: , LOT , BLOCK , FILING (UNIT) <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: <br />must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 orA Zone 13 Easting: 3 IS 12 `7 V <br />STREET ADDRESS AT WELL LOCATION: Northin : SI y8C,16,2 <br />4. GROUND SURFACE ELEVATION 6 rS ?'7 feet DRILLING METHOD Mud etd -A&P q <br />DATE COMPLETED . y • 0 TOTAL DEPTH a O feet DEPTH COMPLETED feet <br />5. GEOLOGIC LOG: 6. HOLE DIAM (n. From ft <br />To(ft) <br />Depth Type Grain Size Color Water Loc. -- <br />%Q 3/Y p <br />2 <br />5 ;L 7-25 <br />10 r' ? <br />`7/ 3 9 V02 0 <br /> <br />IS-110 a- <br />, - A! <br />.C s-s .?0 <br />7. PLAIN CASING: <br />aS' 6Lrd A1 7 OD (in) Kind Well Size (in) From (ft) To (ft) <br /> G L 3&, ee sck 40 t 1 39 <br />Qag- 2t')6 k y 5- <br />AUL s'A <br />y0 U <br />3zo <br />qkjQ cap 11Vr-V E+d{ 61e _ <br />- <br />1 <br />[? 3 0 ?IOD <br />PAC <br /> _ <br />^ <br />390- 110 R' GALS P i- C-?AG' PERFORATED CASING: S <br />reen Slot Size (in): <br /> c <br />A L d Lit ?0 3 6 O 0 <br /> _ <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material UJAfIt Act Type <br /> Size 3 A <br />X <br /> - <br />Interval =- a O ** Depth <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br />Remarks: a <br />Ja 10 co ,";Ai Ce s?'J ?' <br /> <br />?n <br />-7 V <br /> A?.tr?rfr ,rl Co ' a D n+ <br />11. DISINFECTION: T e Amt. Used L 0 <br />12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well,Test. <br />TESTING METHOD _ _? 1 f2 R f,? Gtv J <br />Static Level ft. DatelTime measured: ?i' ` v(Y L?- Production Rate q- gpm. <br />Pumping Level 1 oQ It. Datef'Cime measured J? - Test Length (hrs) 3 <br />Remarks: <br />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 <br />accordance with Rule 17.4 or the Water Well Construction Rules, 2 CCR 402-2. [rhe filing of a document that contains false statements is a violation of <br />section 37.91-1083 t e , C.R.S., and is punishable b fines u to $5000 andlor revocation of the contracting license. <br />Compann??+ Name: <br />st evti P4N?404 /'1 A4A if - Phone., <br />TV a - 9S7 License Number: <br />! - 0 3 <br />Mailing Addres <br />Signature: <br />u' Print Name and Title <br />!34N/?F ?/ - OWA-e-4 Date <br />R.,-A-f .07 <br />