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] http://www.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: MH-048267
2. WELL OWNER INFORMATION
NAME OF WELL OWNER: Lafarge North America
JAN 2 a 2009
MAILING ADDRESS: 10170 Church Ranch Way, Suite 200 'vA"r cti t -SOURCES
CITY: Westminster STATE: CO ZIP CODE: 80021

TELEPHONE NUMBER: 303 657 -4000 STATE ENGINEER
COLO
- --

3. WELL LOCATION AS DRILLED: NE 114, SE 1/4, Sec. 34 Twp. 6 01 N or 0 S, Range 66 E]EorMW
jr
DISTANCES FROM SEC. LINES: ft. from ? N or ? S section line and
FILING (UNIT)
SUBDIVISION: LOT_, BLOCK T
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation:_TT-MW-0066
must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting: 520821.0
STREET ADDRESS AT WELL LOCATION: Northing: 4476734.1
4. GROUND SURFACE ELEVATION 4687.1 feet DRILLING METHOD Hollow Stem Auger
DATE COMPLETED 12-16-2008 TOTAL DEPTH 20.0 feet DEPTH COMPLETED 19.0 feet
6. GEOLOGIC LOG: 6. HOLE DIAM (in.) From (ft) To(
Depth Type Grain Size Color Water Loc. 8" 0 19.01
0-2.3 Sandy Clay Clay, Sand am to Dark Brn 2 19.01 20.0'
2.3-6.5 Silty Sand Silt, Sand Tan 7.40
6.5-18.0 Well Graded Sand Sand, Gravel Tan 7. PLAIN CA:
18.0-20.0 Sandy Claystone Gray OD (in) Kind Wall Size (in) From (ft) To (ft)
2 Sch 40 0.154 TAGS 9.01

PERFORATED CASING: Screen Slot Size (in): .020
2 Sch 40 0.154 9.01 19.01

8. FILTER PACK: 9. PACKER PLACEMENT:
Material " Type No Packer
Size _
Interval 2
10. GROUTING RECORD
Material Amount
Remarks: Concrete 01-11 Pour
Bentoinite 3 Bags 1'-6- 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 8.84 ft. Date[Time measured: 12-17-2008 13:30 Pr
Pumping Level ft. Datefrime measured Test
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
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. Phone:

303 ' 772 -5282 License Number:

PG-3665 -
Mailing Addres :1900 S. Sunset Street, Suite 1-F, Longmont, CO 80501
Signature: Print Name and Title Jeremy Deuto, PG 3te 1-6-2008