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FORM NO. WELL CONSTRUCTION AND TEST REPUI <br />GVVS-31 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />0412005 1313 Sherman St., Room 818, Denver, CO 80203 <br />Phone - Info (303) 866-3587 Main (303) 866-3581 <br />Fax 303 866-3589 h JA~.water.state.co.us <br />L#FLL PERMIT NUMBER: ga ?. <br />NAME OF <br />Q <br />/NC <br />TELEPHONE <br />?/ $? Twp• ? N or 21S, Range Z ? E or 94 <br />WELL LOCALS DR ED: /V 114. 114, Sea <br />DISTANCES FROM SEC. LINES: _- from 0 N or ? S section fine and ft. from ? E or C? section line. <br />SUBDIVISION: LOT BLOCK FILING (UNIT) <br />Owners Well Designatio;''Y ? <br />Optional GPS Location: GPS Unit must use the following settings: Format must be.,,UT..M- ?Units Fasting: yaa a <br />must be meters, Datum must be NAD83, Unit must be set to tare N. ? Zone 12 or tld?or? 13 <br />GROUND SURFACE ELEVATION 8O?? feet DRILLING METHOD <br />- c•rcn 4-/-/o TOTAL DEPTH oZ0•0 feet DEPTH C <br />DIAM <br />O°? r W T/l= G/lJIN/TF ?- ?? <br />7!:.an fWAr/1TS- <br />box if Test Data is submi tea on <br />'. PLAIN CASING: <br />OD (in) Kind Wall Size (n) From (ft) To (ft) <br />a3/a Ape- pR o -- <br />P FORATE CSI G: Screen Slot Size / <br />FILTER PACK 9. PACKER PLACEMENT: <br />Material Type <br />Size <br />10. GROUTING RECORD <br />? T Dens' Interval Placement <br />TESTING METHOD Production Rate 9Pm <br />Static Level ft Date/Tirne measured: Test L (hrs) <br />Pumping Level it Datefi ime measured L? rl . )p /AOf1//7? 11W 4OW4 <br />eaa me srd?e,?a???w •••? •••..•.... _._. ---- <br />with Rule 17.4 of the Water WQ Consi ,on Rides. 2 CCR 402-2. MO <br />it 108(1)(e), C R S and lsP by fines up to 55000 and/or revoci <br />jO„ tA, v j9W /I)AAk <br />-/off <br />ue th my jM0V4Me. I nls (IUC:wnarn N ..• •• <br />of a document that contains false statements is a vioWw of <br />1(3 ")11-463x`3 <br />Ca ,oYS;L <br />Pte. <br />