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FORM NO. WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br />GWS-31 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />04/2005 1313 Sherman St., Room 818, Denver, CO 80203 <br />Phone - Info (303) 866-3587 Main (303) 866-3581 <br />Fax 303 866-3589 htto://www.water.state.co.us <br />1. WELL PERMIT NUMBER: MH- 047209 <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: Powertech (USA) Inc. <br />MAILINGADDRES8:5575 DTC Parkwa Suite 140 <br />CITY:Greenwood Village STATE:Colorado ZIPCODE:80111 <br />TELEPHONE NUMBER: 303 790 - 7528 <br />3. WELL LOCATION AS DRILLED: SW 1/4, NE 1/4, Sec. 3 3 , Twp. 10 ® N or ? S, Range 67 ? E or ® W <br />DISTANCES FROM SEC. LINES: 2500 ft. from ®N or ? S section line and 1400 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: IS-3T <br />must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting: <br />STREET ADDRESS ATWELL LOCATION: East of CR17 & North of CR110 Northin : <br />4. GROUND SURFACE ELEVATION 5539.11 feet DRILLING METHOD Air Rotar <br />DATE COMPLETED 09/07/07 TOTAL DEPTH 495 feet DEPTH COMPLETED 495 feet <br />S. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft <br />olor Water Loc. 10 0 40 <br />Depth Type Grain Size Ff, <br />0 Mudstone Clay 7-7/8 40 495 <br />1 77 Ganr`lCtnnc C=nA 175 Mudstone Clay Gray 10 GPM 7, PLAIN CASING: <br /> <br /> 340 Mudstone Clay Gra OD (in) Kind W <br />ll Si <br /> <br />395 <br />Laramie Fm <br />Sand Jmud <br />Gra a <br />ze (in) From (ft) To (ft) <br />4 SCH 80 0 <br />337 0 4 <br /> <br />436 <br />Al Fox Hs <br />Sand Mud <br />Gra . <br />65 <br /> 462 A2 Fox Hs Sand Gra 35 GPM <br /> 495 Mudstone Cla Mulit <br /> PERFORATED CASING <br />S <br /> : <br />creen Slot Size (in): 0.020 <br />4 SCH 80 0 <br />337 465 4 <br /> . <br />95 <br /> <br /> <br /> R PACK: 9 <br />P <br /> <br />Sand . <br />ACKER PLACEMENT: <br />T <br />N/ <br /> <br />8 -12 ype <br />A <br /> 4 5 5- 4 9 5 Depth N JA <br />TING RECORD <br />E <br /> Amount Densit <br />I <br /> <br /> <br />Remarks: *Grout consists of WYO-BEN <br />Enviroplucl - 30% Solids **Bentoni <br />y <br />nterval Placement <br />109 FT3 10.2 0-452 Pumped <br />Bn <br />*1 FT3 10 <br />2 452-455 <br /> <br />time relase ellets above sand. . <br />Tremie <br />11. DI <br />SINFECTION: T e sed <br />12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Suppiemental Well Test. <br />TESTING METHOD <br />Static Level2 74 . 9 ft. Date/Time measured: Production Rate gpm, <br />Pumping Level ft. Date/Time measured Test Length (hrs) <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 of the Water Well Construction Rules, 2 CCR 402-2. (The filing of a document that contains false statements is a violation of <br />section 37-91-1080)(e), C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license. <br />Company Name: Phone: License Number: <br />Ingram Drillin Inc. 800 410 4542 1099 <br />Mailin Address: P.O. Box 342 Estes Park Colorado 80517 <br />Sign re: <br />?o Print Name and Title <br />Ste hen E. Ingram, President Date <br />oy ng <br />Attachment D