2010-04-06_REVISION - M1979205 ‎(13)‎

• Permit No: M1979205
• IBM Index Class Name: REVISION
• Doc Date: 4/6/2010
• Doc Name: Submit a TR ‎(TR-04)‎
• From: Greg Lewicki and Associates, PLLC
• To: DRMS
• Type & Sequence: TR4
• Email Name: GRM
• Media Type: D
• Archive: No

Gravel
11-it
Owner
FORM No.
GWS-31
! 0412005 WELL CONSTRUCTION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St, Room 818. Denver, CO 60203
Phone - Info [phone] Main [phone]
Fax [phone] htIp:11~v.water.state.co.us ???i?? use ony
lf??

?LP Y 1201
SE
1.. WELL PERMIT NUMBER: 62558 F
2. WELL OWNER INFORMATION Oldcastle SW Group, Inc. dba
NAME OF WELL OWNER: United Com an es of Mesa Count wATERpEaouRCas
STATE CO`piMnak
:MAILING ADDRESS: P. 0. Sox 60
CITY: Grand Junction STATE: CO. ZIP CODE:81502
.TELEPHONE NUMBER: 0 243 -4900
3. WELL LOCATION AS DRILLED: ,aK_114, x_1/4, Sec. 15 .. Twp. , 6 ? N or ® S. Range fir, ? E or ® W
DISTANCES FROM SEC. LINES: 2390 ft. from ®N or? S section line and _ aj-Q_fL from ® E or ? W section line.
SUBDIVISION: LOT___. BLOCK FILING (UNIT)
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation:
must be meters. Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting:
STREET ADDRESS AT WELL LOCATION: 01 Count Road 315, Silt CO. 81652 Notthin :
4. ,GROUND SURFACE ELEVATION 5296 feet DRILLING METHOD
DATE COMPLETED 9112/06 TOTAL DEPTH 4 to 5 feet DEPTH COMPLETED feet
5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Da 1h Type Grain Size Color Water Loc.

7. PLAIN CASING:
OD (n) Kind Wall Size (in) From (ft) To (ft)

PERFORATED CASING: Screen Slot Size (in):

'
8. FILTER PACK: 9. PACKER PLACEMENT:
Material Type
Size
Interval Depth
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks:This report is to show initial develoyme
of a gravel pit excavation that will t _

eventUally u lake, _
11. DISINFECTION: Type Amt Used
12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test
TESTING METHOD
Static Level R Datefrims measured: Production Rate gpm.
Pumping Level IL Date/rime measured Test Length (hrs)
Remarks:
13. 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
accordance with Rule 17A of the Water Well Construction Rules, 2 CCR 402-2. (The filing of a document that contains false statements is a violation of
section 37-91-108 1 e C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license.
Company Name:Oldcastle SW Group, Inc. dba
United Com anieB of Mesa Count Phone:
970 243-4900 License Number:
NA
Mailing Address: P. 0. Box 3609, Grand Junction CO. 81502
Signature: -?/ Print Name and Title
Brent W. Kerr - Resource Manager Date
9/12/06