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
0412005 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] http://www.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: MH- 04 72 09
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: Powertech (USA) Inc.
MAILING ADDRESS: 5575 DTC Parkway, Suite 140
CITY:Greenwood Village STATE:Colorado ZIP CODE: 80111
TELEPHONE NUMBER: 303 790 - 7528
3. WELL LOCATION AS DRILLED: SW 1/4, NE 1/4, Sec. 33 , Twp. 10 ® N or ? S, Range 67 ? E or ® W
DISTANCES FROM SEC. LINES: 2 5 0 0 ft. from ® N or Q S section line and 14 0 0 ft. from
®E or ? W section tine.
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 - 3 Tb
must be meters, Datum must be NAD83, Unit must be set to true N, C3 Zone 12 or Q Zone 13 Easting:
STREET ADDRESS AT WELL LOCATION: East of CR17 & North of CR110 Northin :
4. GROUND SURFACE ELEVATION 5541.24 feet DRILLING METHOD Air Rotary
DATE COMPLETED 09/12/07 TOTAL DEPTH 575 feet DEPTH COMPLETED 575 feet
5. 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 40 575
122 Sandstone Sand Gray
175 Mudstone Clay Gray 10 GPM 7, PLAIN CASING:
340 Mudstone Clay Gray OD (in) Kind Wall Size (in) From (ft) T
ft

395
Sandstone
Sand
Gray o (
)
2 SCH 40 0.125 0 555
495 Mudstone Clay Mulit 35 GPM
510 Sandstone Sand Gray
575 Mudstone Clay Gray
PERFORATED CASING: Screen Slot Size (in
0
020
.
):
2 SCH 40 0.125 555 575

8. FILTER PACK: 9
PACKER PLACEMENT

Material Sand .
:
T
e N/A
Size 8-12 yp
Interval 555-575 De
th N/A
p
0. GROUTING RECORD
Material Amount Density Interval Pl
t
Remarks: *Grout consis ts of WYO-BEN acemen
Grout* 81 FT3 7.8 0-550 Pumped
Enviroplucf - 30% Solids. **Bentonite 1/4' Bent.**0.6 FT3 10.2 550-555 Tremie
time release pellets above sand.
11. DISINFECTION: T e 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 2 6 8 . 3 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 37-91-108 1 j e . C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license.
Company Name:
Ingram Drillin Inc. Phone:
t(800)410-4S42 License Number:
1099
Mailing Address: P.O. Box 342, Estes Park, Colorado 80517
Signatur /r
1- 1' ` d it Name and Title
Ste hen E. Ingram, President
Date ayAP
Attachment D