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WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br />FORM NO. <br />, OFFICE OF THE STATE ENGINEER <br />TATE OF COLORADO <br />GWS-331 S <br />_ <br />818. <br />Sherman <br />1313 <br />0412005 <br />BW3587 Main 303) 866-3581 <br />info (3 3) <br />Phone <br />Fax 303 86&M9 t0;1AvwW.wa19rsWe.co.us <br />1. WELL PERMIT NUMBER: Q4At;Q4_MTj <br />2. WELL OWNER INFORMATION <br />PowerTech (USA), Inc. <br />NAME OF WELL OWNER: <br />MAIUNGADDRESS: 5575 DTC Parkway, Suite 140 <br />CITY: Greenwoo Vi ageSTATE: CO ZIP CODE: 80111 <br />TELEPHONE NUMBER: - 5 <br />WELL LOCATION AS DRILLED. SE 114, NW 1/4, Sec. 3 3 Twp.1 0 IN [I S, Range 6 7 n E or ?] W <br />3 <br />. <br />UNES:?8 ft. from [f N or Q S section line and 2 0 2 ft from ? E or IN W section line. <br />DISTANCES FROM SEC <br />. <br />SUBDIVISION: . LOT , BLOCK FILING (UNIT) <br />Owner's Well Designation: X10 8 _ 3 <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Fasting: <br />must be meters. Datum must be NAD83, Unit must be set to true N, ? Zone 12 or 0 Zone 13 <br />STREET ADDRESS AT WELL LOCATION: Northin : <br /> <br />u Rotary <br />GROUND SURFACE ELEVATION feet DRILLING METHOD <br />DATE COMPLETED TOTAL DEPTH 603 feet DEPTH COMPLETED feet <br />5. GEOLOGIC LOG: S. HOLE DIAM in. From tt TO ft <br />Depth Grain Size Color Water Loc. <br />0-10 Alluvial 10 1/2 580 600 <br />10-417 Laramie <br />41 7-603 F oxH i l l s 7. PLAIN CASING: <br /> OD (m) Kind Well Size (in) From (ft) To <br />1 58trt} <br />0 <br /> 6 PVC SDR17 + <br /> <br /> <br /> <br /> FORATE <br />PE <br />Ch8OSlot s58(0 )._ b 0 <br />VC 1NG <br /> 3 <br />_S <br />P <br /> <br /> <br /> <br /> 8. FILTER PAgf(; S. PACKER PLACEMENT: <br /> Material s ill I c a s <br />1- <br />1 Pe <br /> 2 U <br />U <br />Size <br /> Interval 580-600 De th <br /> Q. GROUTING RECORD <br /> alsDe?s v 3" 1bs teff -580 H llibu <br />1ens 95 mz <br /> B <br />g <br />Remarks: cem <br /> <br />11. DISINFECTION: T we Amt. Used <br />L TEST DATA Check box If Test Data Is submitted on Form Number GWS 39 Supplemental Well Test. <br />1 E <br />L <br />12. <br />TESTING METHOD <br />Static Level It Datell une measured: _?. Production Rate gpm. <br />Pumping Level ft. Date/rune measured Test Length (hrs) <br />Remarks: Monitor well to be tested at a later date. <br />1 have read the statements made herein and know the contents thereof, and they are true to my knowledge. This document Is signed and certliffetl In <br />13 <br />. <br />accordance with Rule 17.4 of the Water Well Construction Rules, 2 OCR 402-2- (The filing of a dorament that contains false statements is a violation of <br />section 37-81-108 1 e , CR.S., and is unishable 11ne3 u to $5000 and/or revocation of Ow oontracUng license. <br />License Number. 1316 <br />Pilpl} <br />Company Name: Sharpe Drilling Company <br />632 9523 <br />3 <br />3 <br />Mailln Addreas:,.P•O. B?C 20147 Cheyenne, WY 8200 <br />Signature: i3rintNameandTiOeLyle Sharpe, President 1Date <br />!' i 4. ?; <br /> <br />3-MU <br />IUU2 <br />ton <br />Attachment E