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WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br />FORM NO. <br />OFFICE OF THE STATE ENGINEER <br />STATE OF COLORADO <br />, <br />GWS41 <br />04/2005 1313 Sherman St., Room 818, Denver, CO 80203 <br />phone - info (303) 866-3587 Main (303) 866-3581 ? <br />Fax 303 888-3589 ://www.waterstate.co.us <br />1, WELL PERMIT NUMBER: 0 4 8 5 0 8 -MH <br />2. We LL O4ftMER INFORMATt P <br />owerTech (USA), Inc. <br />NAME OFWELL OWNER: <br />MAILINGADDRESS: 5575 DTC Parkway, Suite 140 <br />CITY: Greenwood Villa geTATE: CO ZIP CODE 80111 <br />TELEPHONE NUMBER: 3 9 0 _7 5 2 8 <br />3. WELL LOCATION AS DRILLED: 1/4, NW 1/4, Sea Twp. N or QS, Range 0 E or EKW <br />LINES: 609 ft from [ N or j] S section rme and 1 9 ZZ 99 from ? E or MW Section tine. <br />DISTANCES FROM SEC <br />. <br />SUBDMSION: , LOT BLOCK FILING (UNIT) <br />Owner's Well Designation: I N 0 8 - <br />optional GPS Loratlofk: GPS Unit must use the following settings: Format must be UTM, Units Easting: <br />must be meters, Datum must be NAD83, Unfit must be set to true K ? Zone 12 or Q Zone 13 <br />STREET ADDRESS AT WELL LOCATION: Northi : <br />u o ary <br /> <br />DRILLING METHOD <br />GROUND SURFACE ELEVATION feet <br />5 <br />4 8 3 <br />4 8 7 <br />. <br />feet <br />feet DEPTH COMPLETED <br />DATE COMPLETED 9-14-02 TOTAL DEPTH <br />5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft <br />8 3n__ U 46U <br />_.?------? -------- <br />De th TYPS Grain Size Color Water Loa <br />Al 11117ial 5 3t4 - 485 487 <br />41 5- 4 8 7 Is 1 <br />FoxHil 7. PLAIN CASING: <br /> - OD (Irv) Kind Wail Size (m) From (ft) To (ft) <br /> 5 <br />458 <br /> . <br />6 PVC SDR17 +1 <br /> <br /> <br /> <br /> PERFORATED CASING: Screen Slat Size (in): . 0 3 0 <br /> 5 <br />5 483 <br />458 <br /> . <br />. <br />3 PVC -sch80 <br /> <br /> <br /> <br /> 8, FILTER PACK 9. PACKER PLACEMENT: <br /> Material silica s phe <br /> <br /> 10120 <br />Si <br /> ze <br /> intervai 458. 5 - 4 th <br /> G. GROUTING RECORD <br /> Material Am unt Density Interval Placement <br />als 13 lbs 0-459 Hallib <br />715 <br />nt <br />B <br /> g <br />- <br />e <br />"- <br />Remarks: cem <br /> <br />1i. DISINFECTION: Type Amt. Used <br />k box if Test Data Is submitted on Form Number GWS 39 Supplemental Weil Test <br />Ch <br />ec <br />12. WELL TEST DATA: <br />TESTING METHOD <br />Static Level ft. Date/Time measured: Production Rate _ gpm. <br />Pumping Level ft. Datei ime measured Test Length (hrs) <br />Remarks: Monitor well to be tested at a later date. <br />and they are hue to my knowledge. This document is signers and cerd, eti lit <br />de herein and know the contents thereof <br />m <br />t <br />t <br />t <br />, <br />emen <br />a <br />s <br />a <br />13. i have read the s <br />accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402-2. [The MM of a document that contains false statements is a violation of <br />section 37-91-108(1)M, C.R.S., and is punishaNe fines u to $5000 and/or revocation of fns oontracting ttcense. <br />Pita e: License Number: <br />1 <br />Company Name: <br />30?/ 63Z_9523 <br />Sharpe Drilling Company 316 <br />P,O: Box 20147 Cheyenne, WY 82003 <br />'" <br />Maflin Add <br />' <br />sigLiatu_re PrirsiName and Fitle Lyle Sharpe, President Date <br />26-09 <br /> <br />33-MM <br />MM2 <br />rton <br />Attachment E