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WELL CONSTRUCTION AND TEST REPORT For Office Use Only <br />FORM NO. <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />GWS-31 <br />0412005 1313 Sherman St., Room 818, Denver, CO 80203 ' <br />Phone - Inb (303) 8663587 Main (303) 866-3581 <br />Fax 303 866-3589 h Jhvww.water.state.c).us <br />1. WELL PERMIT NUMBER: 49459-MH <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: Exxon Mobil Co oration <br />MAILING ADDRESS: GSC-GP2-224 P. O. Box 2567 <br />CITY: Houston STATE: TEXAS ZIP CODE: 77252 <br />TELEPHONE NUMBER: 281 654-6246 <br />Range ? E or 0 W <br />5 ? N or ® S <br />Tw <br />S <br />, <br />p. <br />ec. <br />3. WELL LOCATION AS DRILLED: N W1/4, SW114, <br />ft. from ? E or ® W section line. <br />from ? N or ® S section line and 109Q <br />ft <br />_ <br />. <br />DISTANCES FROM SEC. LINES: 21? <br />LOT , BLOCK , FILING (UNIT) <br />SUBDIVISION: , <br />Owner's Well Designation: FE V3A <br />Owners <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units <br />g: <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: Northin : <br />. GROUND SURFACE ELEVATION 7157 feet DRILLING METHOD Air Rotary <br />DATE COMPLETED 11/5/2010 TOTAL DEPTH 179 feet DEPTH COMPLETED 179 feet <br />3. GEOLOGIC LOG: 6. HOLE [)]AM rn. From ft To ft <br />Depth Type Grain Size Color Water Loc. 6.25 0 179 <br /> <br />179 <br />1 <br />011 Shale <br />fine <br />bm/b <br />155-160 <br /> <br /> PLAIN CASING: <br /> OD (in) Kind Wall Size (in) From (ft) To (ft) <br /> 4.5 Certalg_k_ .250 +1 134 <br /> 4.5 Certallok .250 174 179 <br /> <br /> <br /> PERFORATED CASING: Screen Slot Size (in): X32 <br /> 4.5 rtalok .250 134 174 <br /> <br /> <br /> <br /> 8. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material Silica Type <br /> Size 8-12 <br /> Interval 130-174 Depth <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br />Remarks: 318chID 1 bkt 174 179 <br /> 3/8chip 1.5 bkt 123 130 <br /> Grout 450 Gal 12# 0 123 <br />11. DISINFECTION: T e Amt. Used <br />12, WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD Airlift <br />Static Level 164.5 ft. Date/Time measured: 11-5-2010 Production Rate < 1 gpm. <br />Pumping Level ft. Date/Time measured Test Length (hrs) <br />Remarks: Minimal rodudion durin airlift <br />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 <br />accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402-2. (The filing of a document that contains false statements is a violation of <br />section 37-91-108 1 e C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license. <br />Company Name: Phone: License Number. <br />Himes Drilling Company (970)242-8893 531 <br />Mailin Addres 0 U. 6 and 50, Grand Junction Colorado 81506 <br />Signature: t c <br />I <br />Print Name and Title <br />Date <br /> Tim Himes Owner 1129/2010 <br />i