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.waterstate.co.us For Office Use Only

.
14ECEW
1. WELL PERMIT NUMBER: MH-048267 E
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: Lafarge North America
JAN 2 Q 70nn
vy
MAILING ADDRESS: 10170 Church Ranch Way, Suite 200 '-/MATER RESOURCES
NGINEER
CITY: Westminster STATE: CO ZIP CODE: 80021 STATE E
COLO
TELEPHONE NUMBER: 303 657 -4000
3. WELL LOCATION AS DRILLED: NE 1/4, SE 1/4, Sec. 34 , Twp. 6K N or ? S, Range 66 ? E or X W
DISTANCES FROM SEC. LINES: ft. from ? N or ? S section line and ft. from ? E or E] W section line.
SUBDIVISION: LOT , BLOCK , FILING (UNIT)
Optional GIPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owners Well Designation: TT-MW-04
must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting: 520435.7
STREET ADDRESS AT WELL LOCATION: Northin : 4476729.8
4. GROUND SURFACE ELEVATION 4688.1 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 Sandy Clay Clay, Sand Brn to Dark Bm 2.92 2 17.0' 18.5'
6.0-14.0 Well Graded Sand Sand, Gravel Tan
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 "'°°c" 1111' Type No Packer
Size
Interval 6'-18.5'(4'-rd Depth
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: Concrete 01-1' Pour
Bentonite 4 Bags 11-5' 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: 12-15-2008 16:00 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
Y