2011-04-29_PERMIT FILE - M2011001 ‎(22)‎

• Permit No: M2011001
• IBM Index Class Name: PERMIT FILE
• Doc Date: 4/29/2011
• Doc Name: Adequacy Review Response- Att. 9- Well Permits
• From: Tetra Tech
• To: DRMS
• 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] htt://www.water.state.co.us For Office Use Only

qF-CF-
1. WELL PERMIT NUMBER: MH-048268
JAN
2. WELL OWNER INFORMATION
Lafarge North America
NAME OF WELL OWNER: 2 Zn

;ygrER R, ?••?UR? S
MAILING ADDRESS: 10170 Church Ranch Way, Suite 200 oTA7 G0L18INt ER
CITY: Westminster STATE: CO ZIP CODE: 80021
TELEPHONE NUMBER: 303 657 -4000
3. WELL LOCATION AS DRILLED: NW 1/4, SE 1/4, Sec. 34 Twp. 6 M Nor ? S, Range 66 ? E or ?¦ W
DISTANCES FROM SEC. LINES: ft. from ? N or ? S section line and 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 Owner's Well Designation: TT-MW-03
Easting: 520265.0
must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13
STREET ADDRESS AT WELL LOCATION: Northin : 4476923.57
4. GROUND SURFACE ELEVATION 4688.3 feet DRILLING METHOD Hollow Stem Auger
DATE COMPLETED 12-15-2008 TOTAL DEPTH 18.5 feet DEPTH COMPLETED 17.0 feet
5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water Loc. 8" 0 17.0'
0-6.0 Clayey Sand Clay, Sand Brn to Dark Brn 2 17.0' 18.5'
6.0-14.0 Well Graded Sand Sand, Gravel Tan 6.49
14.0-18.5 Sandy Claystone Gray 7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
2 Sch 40 0.154 TAGS 7.0'

PERFORATED CASING: Screen Slot Size (in): •020
2 Sch 40 0.154 7.0' 17.0'

8. FILTER PACK: 9. PACKER PLACEMENT:
Material Type No Packer
Size
Interval 18.5'-7'(7'-2.5') Depth
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: Concrete
Bentonite 2 Bags 0'-3' Pour

11. DISINFECTION: T e None Amt. Used
12. WELL TEST DATA: ? Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD Water Level Indicator
Static Level 2.92 ft. Date/Time measured: 12-16-200816:00 Production Rate gpm.
Pumping Level ft. Date/Time measured Test Length (hrs)
Remarks:
13. I 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
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: Tetra Tech, Inc.
1
Phone:
303 772 -5282
License Number.
PG-3665
Mailing Address: 1900 S. Sunset Street, Suite 1-F, Longmont, CO 80501
Signature: Print Name and Title
Jeremy Deuto, PG Date
1-6-2008