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FORM NO. <br />GWS-31 <br />0412005 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) 866581 <br />Fax 343 866-3589 -http:/twww.water.s1aie.co.us For Office Use Only i <br />1. WELL PERMIT NUMBER: 0 4 8 5 0 2 -MH <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: PowerTech USA Inc. <br />MAILING ADDRESS: 5575 DTC Parkway Suit 140 <br />,Q CODE: <br />CITY: rrPenwdpod Ali11mr-STATE: -r <br />- <br />TELEPHONE NUMBER: <br />3. WELL LOCATION AS DRILLED: SW 1/4 NE 114, Sec.3 3 , Twp. 10 ®N or D S, Range 67 ? E or o W <br />DISTANCES FROM SEC. LIMES: 2 0 81 ft. from ® N or n S section fine and '17(12 ft. from ? E or}QVlf section !ire. <br />SUBDIVISION: LOT , BLOCK{ , FILING (UNIT) <br />: <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner'Fasting:s Well Designat!on1:*8.8-= <br />must be motors, Datum must be NAD83, Unit must be set to true N, Q Zone 12 or 0 Zone 13 <br />STREET ADDRESS AT WELL LOCATION: Northin : <br />4. GROUND SURFACE ELEVATION feet DRILLING METHOD Mild Rotavy <br />DATE COMPLETED 9= 0 7 - 0 9 TOTAL DEPTH 528 feet DEPTH COMPLETED 5 2 6 feet <br />S. GEOLOGIC LOG: S. HOLE DIAM Ch.) From ft To (it) <br />De th T Grain Size Color Water Loc. 8 3/4 _n 59-2 <br /> <br />All <br />i <br />l j 10 1/2 _ 502 26 <br />_ <br /> <br />470 <br />1 ) uv <br />a 526 528 <br />5 374 <br />- <br />- <br />_ <br />9. PLAIN CASING: <br /> T OD (in) Kind Wall Size (in) From (ft) To (ft) <br /> 6 PVC SDR17 +1 500 <br /> <br /> <br /> <br /> PERFORATED CASING: Screen Slot Size (in): - 0 3 0 <br /> 3 PVC sch80 - - 2 <br /> <br /> <br /> <br /> 8. FILTER PACK S. PACKER PLACEMiENT: <br /> Material S i l i r a c a ape <br /> Size 1012() <br /> Interval 5 Depth <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br />Remarks: Bent- 829 3 31_0-500 Hal 1 i hnr <br /> cem gals <br /> <br />11. DISINFECTION: Type 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 ft. Date/Time measured: Production Rate gpm. <br />Pumping,Level ft. Date/Time measured Test Length (hrs) <br />Remarks: Moniter well to be tested at a later date. <br />M. 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. [fie filing of a document that contains false statements is a violation of <br />section 37-91-1080)(e). G.R.S., and is punishable b fines u to 5000 and/or revocation of the contract' license. <br />Company Name: <br />Shar e Drilling Company Phone: <br />30'h632-9523 License Number, <br />1316 <br />hAailin Adge5a /; "©•Box 20147 Cheyenne, WY 82003 <br />Si <br />' Print Name and T'rtle 2 6 - 0 9 <br />Lyle Sharpe, <br /> <br />-PW4 <br />PW1 <br />on <br />Attachment E