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WELL CONSTRUCTION AND TEST REPORT For OMM Use Qmy i <br />FORM NO. <br />OF THE STATE ENGINEER <br />OFFICE <br />STATE OF COLORADO <br />, <br />, <br />GINS-31 <br />0412005 1313 Sherman SL, Room 618, Denver, CO 80203 <br />Phone - Info (303) M-3587 Main (303) 865-3561 <br />Fax 303 866-3583 htb:lAvww. r te.oo.us <br />1. WELL PERMIT NUM SSR: 0 4 8 51 1-MH <br />2. WELL OWNER INFORMATION <br />PowerTech (USA), INc. <br />NAME OF WELL OWNER: <br />MAILiNGADDREss: 5575 DTC Parkway, Suite 140 <br />pnkZonA Vi 11-n.- STATE: ZIP CODE -rn <br />CITY: G -p <br />_ <br />TELEPHONE NUMBER: -7529 <br />Twp. q_ N or [7 S, Range „g,Z, ? E or (-jW <br />114, sec. ' 3 <br />LOCATION AS DRILLED: 114 <br />_ <br />, <br />3. WELL <br />DISTANCES FROM SEC. LINES: 9 3 7 fr. from ® N or E) S section lute and 4 81 2 ft. from ? E or aW section line. <br />_, FILING SUBDRASION: LOT BLOCK Owner's Well D(UNITfi'onZ? 0 $ - 3 <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTHI. Units Eassfing: <br />must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 <br />STREET ADDRESS AT WELL LOCATION: Northi : <br />GROUND SURFACE ELEVATION feet DRILLING METHOD Mud Rotary <br />DATE COMPLETED 9-1 0 - 0 9 TOTAL DEPTH 465, feet DEPTH COMPLETED feet <br />S. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ff <br />0442 <br />Depth Type Grain Size Color Water Loc. 8 3 <br />10 1/2 442 464 <br />- -5`.374 - 464 465 <br />_ 7. PLAIN CASING: <br /> n) Fro <br />(ft) <br />Kind <br />D (m) <br />) <br />4 <br />Si <br /> m <br />7 <br />1 <br />4 <br />SD <br /> VC <br />P <br />6 <br /> <br /> <br /> <br /> PERFORATED CASING: Screen Slot Size (in): - 0 10 <br /> 3 PVC sch80 4,0- 461 <br /> <br /> <br /> <br /> 8. RLTER PACK: <br />l 9. PACKER PLACEMENT: <br /> ica s <br />Materfal si 4e <br /> - <br />- <br /> 0T20 <br />1 <br />Si <br /> ze <br /> Interved 441-461 De th <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br /> ls 13 lbs 0-441 Hallibu <br />738 <br />B <br />t <br /> ga <br />en <br />- <br />Remarks: -UUM" <br /> <br />91. DISINFECTION: T e Amt. Used <br />k box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />Ch <br />A <br />ec <br />: <br />12. WELL TEST DAT <br />TESTING METHOD <br />Static Level ft. Dateirtme measured: Production Rate gpm. <br />Pumping Level ft. Date/Time measured Test Length (hrs) <br />Remarks: Monitor well to b - tested at lAt-p-r <br />d the statements made herein and know the contents thereof, and they am true to my knowledge. This dccarnent Is signed and cerbftd in <br />t h <br />ave rea <br />13. <br />accordance with Rule 17.4 of the Water Well Consbucilon Rules. 2 CCR 402-2. (The oiling of a doctimeM that contains false statements Is a violatlon of <br />sec iun 37.91-108 1 e , C.R.S., and Is punishable fines to $5000 and/or revocation of the !22q cfi lo°nse. <br />Phone: License Number. <br />1316 <br />Company Name: <br />Shape Drilling Company 307 329523 <br /> <br />ox 20147 Cheyenne, WY 82003 <br />PO,! $ <br />Mailin A <br />gigue Print Name and Title Lyle Sharpe, President ?tM26-09 <br /> <br /> <br />MM1 <br />ton <br />Attachment E