REVISION - 11/4/2009, 7:43:35 AM-JWD

• Permit No: P2008043
• IBM Index Class Name: REVISION
• Doc Date: 11/3/2009
• Doc Name: MEMO- Previously Confidential Documents Transferred to Public Files
• From: DRMS
• To: File
• Type & Sequence: MD3
• Email Name: ACS
• 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] htte://www.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: MH - 0 4 7 2 0 9
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: Powertech (USA) Inc.
MAILING ADDRESS: 5575 DTC Parkway Suite 140
CITY: Greenwood Villa e STATE: Colorado ZIP CODE: 80111
TELEPHONE NUMBER: 303 790 - 7528
3. WELL LOCATION AS DRILLED: SW 1/4, NE 114, Sec. 3 3 . Twp. 10 ®N or ? S, Range 67 ? E or ® W
DISTANCES FROM SEC. LINES: 2 500 ft. from ® N or ? S section line and 14 0 0 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: IS - 3Ta
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: East of CR17 & North of CR110 Northin :
4. GROUND SURFACE ELEVATION 5542.38 feet DRILLING METHOD Air Rotary
DATE COMPLETED 09/07/07 TOTAL DEPTH 250 feet DEPTH COMPLETED 250 feet
S. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water Loc. 10 0 40
0 Mudstone Clay Gray 6-1/4 40 250
122 Sandstone Sand Gray

175 Mudstone Clay Gray 7. PLAIN CASING:
230 Sandstone Sand -
Gray 10 GPM OD (in) Kind Wall Si
i
F

250
Mudstone
Clay
Gra ze (
n)
rom (ft) To (ft)
2 SCH 40 0
125 0 230
.

PERFORATED CASING
S
Sl
0
0
:
creen
ot Size (in):
.
20
2 SCH 40 0
125 230 250
.

8
FILTER PACK: 9
PACKER P
.
Material Sand .
LACEMENT:
T
N/A
Size 8-12 ype
Interval 230-250 De th N/A
10. GROUTING RECORD
Material Amount Densit
Int
l P

FRema
rks: *Grout consists of WYO-BEN
vironlucf - 30a Solids **Bentonite 1/4' y
erva
lacement
Grout* 81 FT3 10.2 0-225 Pumped
Bent.**0.6 FT3 10
2 225-230 T
i
m
e release pellets above sand. .
rem
e
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
Static Level 12 3 . 8 ft. Date/Time measured: Production Rate gpm.
Pumping Level ft. Date/Time measured Test Length (hrs)
Remarks:
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-DI-1080)(e), C.R.S., and is punishable b fines u to 85000 and/or revocation of the contracting license.
Company Name: Phone: License Number:
Ingram Drilling, Inc. 1(800)410-4542 1099
Mailing Address: P.O. Box 342, Estes Park, Colorado 80517
Signat e:
'^+ Print Name and Title
Stephen E. Ingram, President Date
j o?/off
Attachment D