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• <br />r? <br />f`J <br />WELL CONSTRUCTION AND TEST REPORT For Office Use one <br />E <br />FORM NO. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />G?31 1313 Sharman St.. Room $18, Detnrer, CO 80203 <br />0412005 <br />Phone - trtfo (303) 886-3587 Main (WS) 8883581 <br />Fax 303 9 !/www wabarst08.C0 as <br />-MH <br />i. WELL PERMR NUMBER: <br />WELL OWNER INFORMATION <br />owerTech (USA), Inc. <br />NAME OF WELL OWNER: <br />MAILING ADDRESS: 5575 DTC Parkway, Suite 140 <br />V' 1 lage SSTATE: CO ZIP CODE:- 8 0111 <br />CITY: Greenwood <br />- <br />TELEPHONE NUMBER 303 790 7528 <br />0 S. Range 6 7 [j E or$KW <br />, Twp. N or <br />NE 114 <br />3 <br />3 <br />LED SW 1/4 <br />se- <br />' <br />, <br />, <br />- <br />- <br />1 <br />3, ';? t rx <br />1?TION AS DRIL <br />DISTANCES FROM SEC. ONES: 2315 fL from M N or ? S section file and 3 7 9 2 ft. from ? E orUW section line. <br />SUBDIVISION: LOT BLOCK FILING (UNIT) <br />Owner's Well Designation.:I N 0I 3 <br />_ s Format must be UTNI, Units <br />e the foNo <br />us <br />[I Zone 12 or Q Zone 13 ?' <br />N <br />e set ? true <br />, <br />Unit must <br />Datum must be NAD83, <br />must be motors <br />. <br />STREET ADDRESS AT WELL LOCATION: MO`s <br />Mud Rotary <br />GROUND SURFACE ELEVATION fee DRILLING METHOD <br />,50 3 test <br />9 - 2 - 0 9 TOTAL DEPTH 5 0 5 feet DEPTH COMPLETED <br />DATE COMPLETED <br />S. HOLE DIAM In. From To ft <br />GEOLOGIC LOG: <br />S. 4 477 <br />Depth T Grain Size Color Water Loc. 10 1/2 478 501 <br />501 505 <br />- <br />- 7. PLAIN CASING: <br />ft <br />T <br /> ) <br />o ( <br />OD ('m) land Wall Sae (in) From (ft) <br />6 PVC SDR17 +1 476 <br /> PERFORATED CASING: Screen Slot Size (in): , Q 3 0 <br /> 76 501 <br />h80 <br /> 4 <br />3 PVC - sc <br /> <br /> <br /> . FILTER P1?C}f: <br />ca s S. PACKER PLACEMENT: <br /> <br />r <br /> Mader?l s i I fip, <br /> Size 1 0 / 2 0 <br /> Interval <br />t!. GROUTING RECORD <br />MMaa I Amvunt De Interval Placement <br />als 13 lbs 0-477 Hallibu <br />e 792 <br />r <br />g <br />n <br />Be <br />Remarks: c em <br />111. DISINFECTION: T ? Used <br />ck box a Test Data Is submitted on Form Number GOO 39 Supplemental WeN Test. <br />Ch <br />e <br />12. N1?i>`TEST DATA <br />TESTING METHOD <br />Static Level IL Date/Tune measured: Production Rate . gPm• <br />Pumping Level _ ft. DateiTime measured Test Length (hrs) <br />Remarks: Thta dtxxrment is signed and certltted U <br />13. t have read the stetemerts made hetekt and know the caniena thereof, a they are domy Ii nt that contains ia?e atatemerrfa to s viofatlon of <br />4 of flue V&W VM Consftuc6ar Rules. 2 CCR 402-2. Mo I of a <br />17 <br />l <br />ith R <br />. <br />e <br />u <br />accordance w <br />secdon 37-J1-1 1 e C.RS. and is tines up - to 35000 and/o nwocaeon oleo owaaclify Ocense UCense Number <br />?t. 13 16 <br />Company Name: <br />Sharpe Drilling Company 1(303)6-32 _923 <br />Maui Address: P. O ox 0,1'4`7 Cheyenne, WY 8 2 0 0 3 <br />Signature: Print Name and Title <br />Lyle Sharpe, President 10-26-09 <br /> <br />l` <br />3'=MN <br />IM1 <br />ton <br />Completeness Issue Item #7 Attachment