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WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br />FORM NO. <br />GWS-31 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />8412005 1313 Sherman St, Room 818, Danw, CO 80203 <br />Phone - Info (303) 866-3587 Main (303) 885-3581 <br />Fax 303 886-3589 Jlwsvw.wowzta*.Co.us <br />1. WELL PERMIT NUMBER: 0 4 8 5 0 2 -MH <br />2. WELL OINNER INFORMATION <br />Inc. <br />PowerTech (USA) <br />, <br />NAME OF WELL OWNER: <br />MAILINGADDRESS: 5575 . TC Parkway, Suite 140 <br />CITY: reenwoo i ageSTAtE ZIP CODE: <br />TELEPHONE NUMBER: - <br />WELL LOCATION AS DRILLED: Nl 1t4, NE 914, sec. L3 , TWp_ 10 O N or ? S, Range 67 ? E or M W <br />LINES: 8 U Pc. from [?N or ® S section tine and 4 9 7 7 ft. from 0 E or 6 W section line. <br />DISTANCES FROM SEC <br />. <br />SUBDIVISION: _ LOT BLOCK FILING (UNIT) <br />.. <br />Q <br />s Well DesignationT Tj <br />Owner' <br />g = 3 3 <br />Optlonal GPS Location: GPS Unit must use the following settings: Format must be UTM, Units <br />- <br />M <br />tasting: <br />- <br />1 Zone 13 <br />must be meters, Datum must be NAD83, Unit must to set to true N. ? Zone 12 or E <br />STREET ADDRESS AT WELL LOCATION: North/ : <br />feet DRILLING METHOD Mu Rotary <br />GROUND SURFACE ELEVATION <br />_ <br />DATE COMPLETED _ _ TOTAL DEPTH 6 6 0 feet DEPTH COMPLETED 6 5 8 feet <br />8. GEOLOGIC LOG: S. IMAM (in. From 11 -T0- <br />Dept Type Grain Size Color Water Loa, t <br />,r i 4 <br />639 -658 <br />1 <br /> 72 <br />I () <br />n-in Al 1 11-i al <br /> 5 3/4 658 660 <br />10-507 L m" <br />507-66 FoxHills 7. PLAIN CASING: <br /> OD (in) lend Wall Size (tn) From (ft) To (R) <br /> 6 PVC SDR17 +1 638 <br /> <br /> <br /> <br /> PERFORATED CASING: Screen Slot Size (n): _-0 3 0 <br /> 3 PVC - sch80 638 658 <br /> <br /> <br /> <br /> 8. FILTER PACK S. PACKER PLACEMENT: <br /> Material s 1 i. c a s r <br /> 10 20 <br /> Size <br /> interval 6 38-658 Depth__ <br /> 0. GROUTING RECORD <br /> MateRal Amount Denssirttyy Interval Placement <br />llib <br />3 <br /> ur <br />8 Ha <br />Bent-1040gals 13lbs 0-6 <br />Remarks: cem <br /> <br />11. DISINFECTION: T ypAmt. Used <br />TEST DATA; Check box if Test Data is submitted on Form Number GINS 39 Supplemental Well Test. <br />L <br />. <br />12. WEL <br />TESTING METHOD <br />Static Level fL DateTCime measured: _ . Production Rate gpm. <br />Pumping Level fL Date/Time 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 certified in <br />13 <br />. <br />accordance with Rule 17.4 of the Water Well Conshuclion Rules, 2 CCR 402-2. [The filing of a document that contains false statements Is a violation of <br />section 37-91-1 i e , C.R.S., and is urushable b fines to $5000 and/or revocation of the contracft €ccense. <br />Company Name: Sharpe Drilling Company 1 P 632 9523 License Number. 1316 <br />P.O_r Ox 20147 Cheyenne, WY 82003 <br />Mailing Address--. I/ <br />Signature` , ' f' 1 - <br />_z°i W " Print Name and Title <br />Lyle Sharpe, President a? <br />1 U-26-0 <br />X. -- , - 1`- <br />on <br />Attachment E