REVISION - 3/5/2010, 7:14:17 AM-JWD

• Permit No: P2008043
• IBM Index Class Name: REVISION
• Doc Date: 3/3/2010
• Doc Name: Bond Adjustments
• From: Powertech ‎(USA)‎ Inc.
• To: DRMS
• Type & Sequence: SR2
• Email Name: ACS
• Media Type: D
• Archive: No

FORM NO.
GWS-31
04/2005 WELL CONSTRUCTION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St, Room 818. Demmer, CO 80203
Phone - info [phone] Main [phone]
Fax [phone] tQ7 4Ar"mater-tate.co.us For Office Use Only i
?
WELL PERMIT NUMBER: 0 4 8 51 0 -MH
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: PowerTech (USA), Inc.
MAILING ADDRESS: 5575 DTC Parkway, Suite-'140
CITY: reenwoo i age STATE: ZIP CODE:
-
_
28
TELEPHONE NUMBER: 003 )750 75
-
71
3. YVELL LOCATION AS DRILLED. N 1441 NE 1/4, Sea 15 Tvrp. 9N or ? S, Range ? E or (] W
DISTANCES FROM SEC. LINES: It. frmn 8 N or 0 S section tine and 4 8 6 5 it from 0 E or)ffW section tine.
SUBDIVISION: LOT BLOCK. FILING (UNIT)
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well DesignationT N n A _ 1
must be mefe s, Datum must be HAD83, Unit must be set to true N, 0 Zone 12 or 0 Zone 13 Fasting:
STREET ADDRESS AT WELL LOCATION: Northin :
4. GROUND SURFACE ELEVATION feet DRILLING METHOD Mu Rotary
DATE COMPLETED 9 - 8 -'0 9 TOTAL DEPTH 2 6 3 feet DEPTH COMPLETED 6 2 feet
S. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water Loa 0 243
10 1/2 243 263

250-263 FoxHills . PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
6 PVC SDR 17 +1 242

PERFORATED CASING: Screen Slot Size (in):. D
U
0
_
3 PVC sch80 242 262

8. FILTER PACK: PACKER PLACEMENT:
9
Material s l 1 C a s a %
"Ifim
Size 1 n .?
Interval 2
42-96-2 De th
-
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: ¢2.-? 111h-, - 9 4 _ j4 k
em gals

11. DISINFECTION: 7 Amt Used
12. WF,LL. ES DATA: 0 Check box if Test Data Is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD
Static Level fL Dateffime measured: Production Rate gpm.
Pumping Level R Date/Time measured - Test Length (hrs)
Remarks: Monitor well to be tested-at a later date
13. t have read the statements made herein and kriml the contents thereof, and they are true to my knowledge. This document is signed and certified in
accordance with Rule 174 of the Water Well Construction Rutes, 2 OCR 402-2. (The fling of a document that contains false statements Is a violation of
section 37-91-1 1 e . G.R.S. and Is punistatble by tines to $6008 andtor revocation of the contra koense.
Company Name:
SYiar e Drillin Com an 1 Phone:
[phone] License Number:
1316
Maiiin •0. -Box 20147 Cheyenne, WY 82003
Print Name andTitlee Lyle Sharpe, President Date

Attachment E
-MM1
)n