2010-04-08_PERMIT FILE - M2008012

• Permit No: M2008012
• IBM Index Class Name: Permit File
• Doc Date: 4/8/2010
• Doc Name: Response to Preliminary Adequacy Review
• From: BCI
• To: DRMS
• Email Name: GRM
• Media Type: D
• Archive: No

FORM NO.
WELL CONSTRUCTION AND TEST R1 =PORT
For Office Use Only
GWS-31
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
0412005
1313 Sherman St, Room 818, Denver, CO 80203
Phone -- Info (303) 866 -3587 Main (303) 866 -3581
Fax [phone] h!!2:f1www.water.state.co.us
1. WELL PERMIT NUMBER: MH - 48032
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: Nuvemco, LLC
MAILING ADDRESS: 10771 3200 Road
CITY: Hotchkiss STATE: CO : ZIP CODE: 81€19
TELEPHONE NUMBER: 970 872 - 3009
3. WELL LOCATION AS DRILLED ± ! E 114, SE 1114, Sec. 18 Twp. 46 ❑ N or ❑ S. Range 17 ❑ E or ❑ W
DISTANCES FROM SEC. LINES; % from ❑ N or ❑ S section line and ft from ❑ E or ❑ W section line.
SUBDIVISION: __ . LOT , BLOCK FILING (UNIT)
owner's Designation: i191y1W2
Well D 7.7
Optional GPS Location: GPS Unit must use the follov�ng settings: Format must be UTM, units Fasting: m N
must be meters, Datum must be NAD83, Unit must be set to true N, 0 Zone 12 or E] Zone 13
STREET ADDRESS AT WELL LOCATION: NA Northing: 4234 543.5 m W
4. GROUND SURFACE ELEVATION 6629 feet DRILLING METHOD Air Rota
DATE COMPLETED 10 -1 -08 TOTAL DEPTH feet DEPTH COMPLETED 10 -1 -08 feet
5. GEOLOGIC LOG:
6. HOLE DIAM (in.)From ft To it
Depth
Type
Grain Size
Color
Water Lac,
6 0 210
7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
2 318 PVC 3116 +2 133
2 318 PVC 3116 168 153
PERFORATED CASING: Screen Slot Size (in): 20
2 316 PVC _aLt6__ 133 153
PLACEMENT:
SEE - FOLLC
WING PAG�
1
8. FILTER PACK: 9. PACKER
Material sand Type nla
Size 10-20
Interval 155 -130 1 De th
G
j
10. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: hole was very dry to TD and on subsequent days. Bnt Pellet 6 buckets 168 455 hand
Brit Chips 5 sx 10-3 hand
cement 2 sx 3- surface hand
11. DISINFECTION: Type NA Amt_ Used
12. WELL TEST DATA: ❑ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD Dry
Static Level NA ft DatelTime measured: 10 -2 -08,10 am . Production Rate 0 8pm•
Pumping Level NA I it. Dateirime measured 10-2-08,10 am J Test Length (hrs)
Remarks: Borehole was d
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
document that contains false statements is a violation of
accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402 -2. [The filing of a
section 37 -91 -108(1)(q2, C.R.S., and is punishable by fines up to $5000 and/or revocation of the contracting license. License Number.
Company Name: Phone: CPG -10493
O &G Environmental Consulting 720 529- 9777
i
11 Inverness Way South, Englewood, CO 80112
Mailin Address:
Signature Date
: Print Name and Title
,�CJyi E. Thomas Cavanaugh Operations Manager 11 -02 -08
J