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] http://www.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: A15746
2. WELL OWNER INFORMATION /
NAME OF WELL OWNER: JC 0A v?a l Lle, v C Ti 5-
- ADDRESS: 7
CITY: STATE: T ZIP CODE: 72 S2
TELEPHONE NUMBER: Z - G q 6
3. WELL LOCATION AS DRILLED: IV W1/4, FW1/4, Sec. 7 , Twp. S ? N or ® S, Range $ ? E or ® W
DISTANCES FROM SEC. LINES: 20q cr ft. from ? N or [M S section line and 224 ft. 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 Owners Well Designation: WlflcGi01
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 70 B 3, S feet DRILLING METHOD Aa le, A,.
DATE COMPLETED r r,4 { ! TOTAL DEPTH O l feet DEPTH COMPLETED JL)cj feet
GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water Loc.

?j
7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
4,5 vG .2 *-t c. +
_
4.5 Pya 0.25 10 4 10

PERFORATED CASING: Screen Slot Size (in): AX
4.5 eVC-_ 0.25 64 to*-

8. FILTER P{ FK: 9. PACKER PLACEMENT:
Material St(w- s Type
Size R -/2 +-
Interval -60¢ Depth
-?
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: an ,.,coca. wc?ri
2.l u.? 3G ?- brow ?,rOtiw? ,?•c% ,?- SGG ?cc G 2
-_ ?

11. DISINFECTION: T e Amt. Used -'
12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD R-OLA &ft •a-
Static Level 74.23 ft. Date/rime measured: 2 -1 8 ! Production Rate OLL gpm.
Pumping Level 16 ft. Date/Time measured 3 2- It *- 13 4 Test Length (hrs) W3 S
Remarks: !ta'? t a., Oww+e•`S ro e... ??i??e ,
13. 1 have read the statements mad herein and know the ntents 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 Pr ^ _ //?
a. ^? O avtYS /NG Phone:
R7O License Number:
Z 4SS J
Mailing Address: -7t 5 rh ?`i?G v, 't 34-6 G «.d Jkiw X-t GO $r! O 6
Signature: Print Name and itle
II
l / t(ftwf rrNG, A?
Date
4 1
U V,