2011-04-08_REVISION - M1980047

• Permit No: M1980047
• IBM Index Class Name: REVISION
• Doc Date: 4/8/2011
• Doc Name: Form GWS-31 submittal ‎(TR-14)‎
• From: Agapito Associates, Inc.
• To: Office of the State Engineer
• Type & Sequence: TR14
• Email Name: THM
• 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, Denver, CO 80203
Phone - Info [phone] Main [phone]
Fax [phone] ht1p:/Avww.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: 4 S L 6 4-)
2. WELL OWNER INFORMATION /
NAME OF WELL OWNER: -gdN A40bi I Cdr . G D , L /4olgii h
MAILING ADDRESS: FQ 0,0 A 2. S 7
CITY: STATE: % ZIP CODE: Z
TELEPHONE NUMBER: (2,91 X.94 - G 46
3. WELL LOCATION AS DRILLED: N U/ 1/4, X1/4, Sec. _Z. Twp. _ ? N or S, Range _ ? E or ® W
DISTANCES FROM SEC. LINES: 2408 ft. from ? N or DQ S section line and 9 74 ft. from ? E or IK W section line.
SUBDIVISION: -+ , LOT ^ BLOCK - , FILING (UNIT) --
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owners Well Designation:WWC0
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: Northin :
GROUND SURFACE ELEVATION 7083.0 feet DRILLING METHOD _QWk*iAd1e_ cr aim cr
DATE COMPLETED rcJD Z 20l 1 TOTAL DEPTH feet DEPTH COMPLETED feet
5. GEOLOGIC LOG: S. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water Loc. ?w• S ; p /OS; Z
6.7 ,. eN a ;ve r

7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
4,5 Pyc 0.2s +r, 60
4.5 P y G 0.15 100 l 0s 2

PERFORATED CASING: Screen Slot Size (in): L!
03Z
,
4.S VG 0.29 GO to

8. FILTER P CK: 9. PACKER PLACEMENT:
Material S fear. L Type '-'
Size d2 f"
Interval 60-106 Depth
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: n c v?u G C% L
3U Lam" ? w a rowL S w' c'c 5y f_1 w e-

11. DISINFECTION: T e -? Amt. Used --?
12. WELL TEST DATA: 0 Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD P% e.., ?.•
Static Level Z3. S ft. Date/Time measure : 7- 2.8 ?l Production Rate
9Pm.
Pumping Level 95 ft. Datelrime measured 3 7- ll G? 1¢STest Length (hrs) 0.57
Remarks: q i clown j)E Owat.`5 lam- ?csew??-,
13. 1 have read the state eats made herein and know the content thereof, and they are true to my knowledge. This document is signed and certified in
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
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:
AQW-917-0 54AGCAMS iHC-. Phone:
Y'70 242-- 4-Z0 J License mber:
01
Mailin Address: 719 EfVA1 A/ D)UPAC-0 TE 34-0 A60 UA/rrjr)Ao1 C!j IS*to
Signature: yy
v?- rint Name and Title
A.FSt d ,r&r atu r L Date
Q- U