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FORM NO. <br />GWS-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: MH- 047209 <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: Powertech (USA) Inc. <br />MAILING ADDRESS: 5575 DTC Parkway, Suite 140 <br />CITY:Greenwood Village STATE:Colorado ZIP CODE: 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 D S, Range 67 0 E or 0 W <br />DISTANCES FROM SEC. LINES: 2500 ft. from ® N or 0 S section line and 14 0 0 ft. from ® E or 0 W section line. <br />SUBDIVISION: , LOT , BLOCK , FILING (UNIT)Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: I S - 3Td <br />must be meters, Datum must be NAD83, Unit must be set to true N, D Zone 12 or 0 Zone 13 Easting: <br />STREET ADDRESS AT WELL LOCATION: East of CR17 & North of CR110 Northin : <br />4. GROUND SURFACE ELEVATION 5539. 185 feet DRILLING METHOD Air ' Rotary <br />DATE COMPLETED 09/12/07 TOTAL DEPTH 495 feet DEPTH COMPLETED 495 feet <br />5. GEOLOGIC LOG: 6. HOLE DIAM (in) From ft To ft <br />Depth Type Grain Size Color Water Loc. 10 0 40 <br />0 Mudstone Clay Gray 6-1/4 40 495 <br />122 Sandstone Sand Gray <br />175 Mudstone Clay Gray 10 GPM 7. PLAIN CASING: <br />340 Mudstone Cla Gray OD (in) Kind Wall Size (in) From (ft) To (ft) <br />395 Sandstone Sand Gra 2 SCH 40 0.125 0 465 <br />495 Mudstone Mud Gray 35 GPM <br /> <br /> <br /> PERFORATED CASING: Screen Slot Size (in): 0.020 <br /> 2 SCH 40 0.125 465 495 <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material Sand Type N/A <br /> Size 8-12 <br /> Interval 455-495 Depth N/A <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br />Remarks: *Grout consists of WYO-BEN <br />Enviroplua - 30% Solids. **Bentonite 1/4' Grout* 81 FT3 10.2 0-452 Pumped <br />Bent.**0.6 FT3 10.2 452-455 Tremie <br />time release pellets above sand. <br />11. DISINFECTION: T e Amt. Used <br />12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level 275 . 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 37-91-108 1 e , C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license. <br />Company Name: <br />Ingram Drilling, Inc. Phone: <br />800 410-4542 License Number: <br />1099 <br />Mailing Address: P.O. Box 342, Estes Park, Colorado 80517 <br />Signatu Print Name and Title <br />Stephen E. Ingram, President Date <br />ag.3o° <br />Attachment D