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
0412005
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] hftp://www.water.state.co.us
For Office Use Only
1. WELL PERMIT NUMBER: MH-048268 ????
2. WELL OWNER INFORMATION Lafarge North America
NAME OF WELL OWNER: JAN 2 0 2009
MAILING ADDRESS: 10170 Church Ranch Way, Suite 200 MATER R 'SOURCES
CITY: Westminster STATE: CO ZIP CODE: 80021 STATE E GINEER
COLO
TELEPHONE NUMBER: 303 657 -4000
3. WELL LOCATION AS DRILLED: SE 1/4, SW 1/4, Sec. 34 , Twp. 6 9 N or ? S, Range 66 ? E or ?Q 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-09
must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting: 519767.6
STREET ADDRESS AT WELL LOCATION: Northin : 4477537.627
GROUND SURFACE ELEVATION 4688.596 feet DRILLING METHOD Hollow Stem Auger
DATE COMPLETED 12-15-2008 TOTAL DEPTH 31.4 feet DEPTH COMPLETED 31.0 feet
5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water LOC. 8" 0 31.0'
0-3.0 Clayey Sand Clay, Sand Bm to Dark Bm 2 31.0' 31.4'
3.0-29.0 Well Graded Sand Sand, Gravel Tan 6.49
29.0-31.4 Sandy Cla stone Gray 7. PLAIN CASING:
OD (in) Kind Wall Size (in) From (ft) To (ft)
2 Sch 40 0.154 TAGS 21.0'

PERFORATED CASING: Screen Slot Size (in): •020
2 Sch 40 0.154 21.0' 31.0'

8. FILTER PACK: 9. PACKER PLACEMENT:
Material Natural Cave Type No Packer
Size
Interval 31.4'-7' Depth
0. GROUTING RECORD
Material Amount Density Interval Placement
Remarks: Concrete 01-1' Pour
Bentonite 3 Bags 11-T Pour

11. DISINFECTION: T 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 3.27 ft. Date/Time measured: 12-16-200811:00 Production Rate gpm.
Pumping Level ft. Date/Time measured Test Length (hrs)
Remarks:
13. 1 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. Phone:
303 772 -5282 License Number:
PG-3665
Mailing Address 1900 S. Sunse treet, Suite 1-F, Longmont, CO 80501
Signature: Print Name and Title Jeremy Deuto, PG Date 1-6-2008