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WELL CONSTRUCTION AND TEST REPORT For Once Use Only <br /> <br />QW STATE OF COLORADO, OFFICE, OF THE STATE ENGINEER <br />FOB NO <br />S-3t <br />0412005 1313 Sherman St., Room 818, Denver, CO 80203 <br />Phone - Info (303) 866-3587 Main (303) 868-3581 <br />Fax 303 866-3589 hUDJ1Www.water-qtaW.co.us <br />1. WELL PERMIT NUMBER: 0 4 8 5 0 2 -MH <br />2. WELL OWNER INFORMATION <br />PowerTech (USA), Inc. <br />NAME OF WELL OWNER: <br />MAILING ADDRESS: 5575 DTC Parkway, Suite 140 <br />CITY: Greenwood Villa eSTATE: CO ZIPCODE: 80111 <br />TELEPHONE NUMBER 3 0 3 7 9 0- 7 5 2 8 <br />Range 0 E or E3 W <br />10 ff N or ? S <br />3 3 T <br />NE <br />, <br />wp. <br />114, Sec <br />3, WELL LOCATION AS DRILLED: W 4, <br />DISTANCES FROM SEC. LINES: _ ft. from [TN or [] S section tine and 3 6.9 8 ft from ? E or 6 W section line. <br />SUBDIVISION: _ LOT BLOCK FILING (UNiTQ_-j-0 8 - 3 <br />ion: <br />Owner's Well besignat <br />Optional GPS Location: GPS Unit must use the foiloyAng settings: Format must be UTM, Units <br />Fisting: <br />must be meters, Datum must be NA083, Unit must be set to true N, ? Zone 12 or ? Zone 13 <br />STREET ADDRESS AT WELL LOCATION: Northin : <br />Mu Ro ary <br />GROUND SURFACE EI-E1/ATIOf4 feet DRILLING METHOD 5. <br />9 <br />DATE COMPLETED 9 - 2 2 - 0 9 TOTAL DEPTH 601 feet DEPTH COMPLETED feet <br />S. GEOLOGIC LOG: G. DIAM in. From ft To ft <br />Depth Type Grain Size Color Water Loc <br /> 10 1/2 584 599 <br />n10 <br />- Al 1 iiyial <br />- mip 5574 599 601 <br />460-601 FoxHills 7. PLAIN CASING: <br /> OD fm) Kind Wall Size (n) From (ft) To (ft) <br /> 6 PVC SDR17 +1 582.5 <br /> <br /> <br /> <br /> PERFORATED CASING: Scr n Slot Size <br />80 58Z 597 <br /> 3 PVC _ sci <br /> <br /> <br /> <br /> 8. FILTER P> QK: 9. PACKER PLACEMENT: <br />d <br /> Materials i l c a s a <br />-- Type, <br /> 1 077U <br /> size <br /> Interval 582- 59 7 Depth <br /> 0. GROUTING RECORD <br /> LL <br />ert- °'galsellbsn?n--a583 HaTlmibu i <br /> <br />Remarks: c em <br /> <br />14. DISINFECTION: Type Amt Used <br />WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test <br />12. <br />TESTING METHOD <br />Static Level fL Date/Time measured: Production Rate gpm• <br />Pumping Level ft. Date(Time measured Test Length (hre) <br />go- or well to be tested a a a er date. <br />Remarks: <br />i have read the statements made herein and tmow the contents 8?ereof, and they am We to my Kumwiedge. This document is signed and certified in <br />13 <br />. <br />accordance with Rule 17.4 of the Water Web Construction Rules, 2 CCR 402-2. [The fling of a docnnnent that contains false statements is a v olatlon of <br />section 37-91-1 1)(e). C.R.S., and is unish bts, fines to $5001) arWor revocation of Ow contra Hcense. <br />License Number. <br />1 31 6 <br />Company Name: 3 0/? 6 3 2 9 5 2 3 <br />Sharpe Drilling Company <br />".-)Box 20147 Cheyenne, WY 82003 <br />P.0 <br /> <br />, <br />r <br />Malting Address: <br />Signatutxl. <br />- Print Name and Title L le Sharpe President <br />Y , D? <br />110-26- <br />) ,? <br />' <br />I / - <br />3 -MU <br />MU1 <br />on <br />Attachment E