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WELL CONSTRUCTION AND TEST REPORT For Once Use Only <br />FORM 31 NO. <br /> <br />GW5 J1 <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />04=DS 1313 Sherman St., Roam 818, Denver, CO 80203 <br /> Phone - Info (303) 866-3587 Main (303) 858-3581 <br /> Fax 303 866-3589 jMWW.WaWstate.co.uS <br />1. WELL PERMIT NUMBER- 0 4 8 5 0 9 -MH <br />2. WELL OWNER INFORMATION PowerTech (USA), Inc. <br />NAME OF WELL OWNER: <br />MAILING ADDRESS: 5575 DTC Parkway, Suite 140 <br />CITY: reenwoo i ag STATE: ZIP CODE: <br />TELEPHONE NUMBER: - <br />3. WELL LOCATION AS DRILLED: 114, IV 1t4, Sec. Twp. [ N or El S, Range ? E or ? W <br />IL from K1 N or ? S section rme and 3 3 2 0 fL from Q E or 0 W secflon line. <br />3 33 3 5 <br />S <br />? <br />: <br />DISTANCES FROM SEC. LINE <br />SUBDIVISION: . LOT__. BLOCK FILING (UNIT)_-IN08-3 <br />' <br />s Well Designation: <br />Owner <br />Optional GPS Location: GPS Unit must use the foilovAng settings: Format must be UTK Units Fasting: <br />must be meters, Datum must be NA083, Unit must be set to true N, El Zone 12 or ? Zone 13 <br />STREET ADDRESS AT WELL LOCATION: NodWng: <br />GROUND SURFACE ELEVATION, feet DRILLING METHOD mud Rotar _ <br />590 <br />feet <br />DATE COMPLETED _ _ TOTAL DEPTH 591 feet DEPTH COMPLETED <br />S. GEOLOGIC LOG: S. HOLE in. From ft To (ft) U b64 <br />Depth T Grain Size Color Water Loc. 10 172 564 - 589 <br />5 3/4 - 589 591 <br />10-516 Laramie <br />9 1 T. PLAIN CASING: <br />1 - 5 <br />- <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />6 PVC SDR17 +1 563 <br />PERFORATED CASING: Screen Slot Size (in): . 0 3 0 <br />3 PVC sch80 563 589 <br /> 8. FILTER PACK: 8. PACKER PLACEMENT: <br /> Matesilica sa fe <br /> Size 0/20-- <br /> Interval 563-589 Depth <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br /> llib <br />5 <br />4 <br /> : <br />Ha <br />6 <br />Bent- 925ga1s 13 lbs 0- <br />Remarks: <br />c em <br /> <br />11. DISINFECTION: T e Amt. Used <br />12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GM 39 Supplemental Well Test <br />TESTING METHOD <br />Static Level it Datefrime measured: Production Rate gpm. <br />Pumping Level ft. Datefrime measured Test Length (hrs) <br /> <br />at a later date- <br />Remarks: Monitor well to be--tested <br />they ate true to my knowledge. This document is Signed and certified in <br />1 have read the statements made herein and know the contents thereof, and <br />13 <br />. <br />accordance with Rule 17A 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 i e . C.R.S. and is unishabta tines to $5000 and/or revocation of the contract[w license. <br />Phone: License Number: <br />Company Name: <br />1316 <br />Sharpe Dr;lling Company 307 632 9523 <br />4'7 Cheyenne, WY 82003 <br />P Bo <br />2R <br />, <br />, <br />Mailin Address <br />signature: r Print NameanaTitleLyle Sharpe, President 126-09 <br />- - ___ <br />3-MM <br />MM4 <br />rtor <br />Attachment E