2011-05-19_HYDROLOGY - M1980047

• Permit No: M1980047
• IBM Index Class Name: HYDROLOGY
• Doc Date: 5/19/2011
• Doc Name: Form GWS-46
• From: Exxon Mobil
• To: DRMS
• 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] htt://www.water.state.co.us For Office Use Only
1. WELL PERMIT NUMBER: 4 4 566 -. H
2. WELL OWNER INFORMATION /
NAME OF WELL OWNER: F-Aydm /UObi I CL, . r-16 T. L.. Adam 5
MAILING ADDRESS: PQ Oe 567
CITY: STATE: % ZIP CODE: Z
TELEPHONE NUMBER: (2_421 )r.94 - G kro
3. WELL LOCATION AS DRILLED: 4 U/ 1/4, 5 6V 1/4, Sec. --Z- Twp. S ? N or CR S, Range -jeL*_ ? E or M W
DISTANCES FROM SEC. LINES: X408 ft, from ? N or (Q S section line and 9 74 ft. from ? E or Pq W section line.
SUBDIVISION: -+ , LOT - BLOCK - , FILING (UNIT) --

wWu1D1
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation:
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 :
4. GROUND SURFACE ELEVATION 70,$3.0 feet DRILLING METHOD k4A Adler fktWfti,-ai, sr
DATE COMPLETED r"27, 201 1 TOTAL DEPTH feet DEPTH COMPLETED 1 feet
5. GEOLOGIC LOG: S. HOLE DIAM in. From ft To ft
Depth
-
- Grain Size Color Water Loc. (o, S p (t9? 2
06.7 Z
Isfll
le- _
(titI
7
PLAIN CASING:
.
OD (in) Kind Wall Si
i
F
ft
ze (
n)
rom (
) To (ft)
4,.S* PVC 0-i s + I S
4.5
PUG 0.25 106 la&z
_
_

PERFORATED CASING: Scr
Sl
t Si
i
3Z
een
o
ze (
n): -00
1,6 V G b
z S 60 to
.
-

8. FILTER PACK: 9
PACKER PL

Material Sj
? ? .
ACEMENT:
T
-"'
,
Size 8-4?- on ype
Interval 60-106 Depth
-'
0. GROUTING RECORD
Material Amount Densit
Interval Pl
t
Remarks: encv?w 6 Cdf. 2Lu y
acemen
Let-

11. DISINFECTION: Type -? Arnt Used --
12. WELL TEST DATA: M Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
TESTING METHOD w, car a?
Static Level z3• D ft. Date/Time measure : 7-12-101 11 Production Rate .? gpm.
Pumping Level ft. Datelrime measured 3 1) lL ?¢,S• Test Length (hrs) G.
Remarks: q ?• ?or.e 0&-,--C"5 5 7
P? ics?K i??-.
13. 1 have read the state ents made her din and know the content 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:
P1 TO A-k 506L-4 MS /JUG.
I .
Phone:

`!?D 242- ?2Z?
License Number:

I
Nlailin Address: 71S #VRi v- 7-F- 340 ,VA UA/GTldd/ G!9 1506
Signature:

y Print Name and Title Date
? ?? I --tl,CF
oL A ?s? d ?a7' fLtu r L $ 6!
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