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<br />3 <br />WELL CONSTRUCTION AND TEST REPORT For office Use Only <br />FORM NO. STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> <br />O 005 1313 Sherman SL, Room 818, Denver, CO 80243 <br />44122005 <br />Phone -Into (303) 885-9587 Main (343) 888-3581 <br />Fax 309 865-3589 JMRVw.waterstate.co.us <br />4800 <br />1. WELL PERMIT NUMBER: 0 5 -MH <br />2. WELL Cv1INER INFORMATION PowerTech (USA), Inc. <br />NAME OF WELL OWNER: <br />MAILINGADDRESS: 5575 DTC Parkway, Suite 140 <br />CITY. Greenwood Villa @TATE: CO zip CODE: 80111 <br />- <br />0 = 7 5 2 8 <br />TELEPHONE NUMBER: 3 0 3 7 9 <br />WELL LOCATION AS DRILLED: NE 114, SE 1/4, SM3 3 Twp. 10 In N or ? S, Range 6 7 [1 E or [[FW <br />3 <br />. <br />DISTANCES FROM SEC. LINES: 3811 fL from 0 N or ? S section Pine and 4 213 fL from ? E or n W section line. <br />SUBDIVISION: , LOT , BLOCK FILING (UNIT) <br />Owner's Well DeslgnatianZ N 0 8 - 3 <br />Optional OPS Location: GPS Unit must use the following settings: Format e? ?a <br />Fasting: <br />3 <br />must be meters, Datum must be NA083, Unit must be set to true N, <br />STREET ADDRESS AT WELL LOCATION: Northi : <br /> <br />Mud Rotary <br />GROUND SURFACE ELEVATION feet DRILLING METHOD <br />. <br />DATE COMPLETED 9 - 2 - 0 9 TOTAL DEPTH 475.5 feet DEPTH COMPLETED 4 feet <br />S. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To fi <br />1/4 V 446 <br />b <br />- <br />- <br />De T Grain Size Color Water Loc. <br />10 1/2 446 470 <br />-1 5 3/4 470 475.5 <br />41 - 5 5 1 7. PLAIN CASING: <br /> OD (m) Kind Wall Size (in) From (ft) To (ft) <br /> 1 444 <br />1 <br /> 7 + <br />6 PVC SDR <br /> <br /> <br /> 030 <br />S <br /> cot Size (in): <br />PERFORATED CASING: Some <br />sch0 444 -? 69 <br />3 PVC <br /> __ <br /> <br /> <br /> <br /> 8. FILTER PACK: S. PACKER PLACEMENT: <br /> Materials i l i c a s a Type <br /> I U720 <br /> Size <br />475 " <br /> Interval De th <br /> D. GROUTING RECORD <br /> Ma Amo nt Densry Interval Placement <br />444 Hallibu <br />Bent- 743gals 13 lbs 0- <br /> _ <br />marks: <br />R <br />e c em <br /> <br />11. DISINFECTION: T e Amt Used <br />12. WEi. L TF-§IDATA: Check box if Test Data is submitted on Farm Rumber Gilds 39 Supplemental Well Test. <br />TESTING METHOD <br />Static Level ft. Daterrime measured: Production Rate gpm- <br />Pumping Level ft. -nate/Tiime measured Test Length (hrs) P _; <br />_V3' toy well to be tested at a later date. <br />Remarks: <br />made herein and know the contents thereof, and they are true to my kria ledge. This document is signed and rxrtlfied in <br />t <br />t <br />t <br />s <br />emen <br />a <br />13. I have read the s <br />ac oordance with Rule 17.4 of the Water Weft Conshudon Rules, 2 CCR 402 2. [The flung of s document that contains false statements is a violation of <br />section 37-91-10 1 e . C.R.S. and is un+shable fines to $5040 andlor revocation of on contractim License. <br />Phone: License Number 1316 <br />Company Name: <br />Sharpe Drilling Company 07 632-9523 <br />-4 (3 <br />Mailing Address: P.O.!Box 20147 Cheyenne, WY 82003 <br />signature:. TI PrintName and Title <br />Lyle Sharpe, President 10-26-09 <br />L <br />A'a - <br />r <br /> <br />I -MMI <br />MM5 <br />rtor. <br />Attachment E