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FORM NO. <br />GWS-31 <br />04/2005 WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St., Room 818, Denver, CO 80203 <br />Phone - Info (303) 866-3587 Main (303) 866-3581 <br />Fax 303 866-3589 htt://www.water.state.co.us For Office Use Only <br />1. WELL PERMIT NUMBER: A G fo -AIH <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: F aA v?i v c D 7 a ». S <br />MAILING ADDRESS: 7 <br />CITY: STATE: 7' ZIP CODE: 772-S?- <br />TELEPHONE NUMBER: Z - G 4 6 <br />3. WELL LOCATION AS DRILLED: NIA/1/4, J1/4, Sec. 7 , Twp. s ? N or ® S, Range T S ? E or ® W <br />DISTANCES FROM SEC. LINES: 2OT'7 ft. from ? N or ® S section line and 2?4 ft. from ? E or ® W section line. <br />SUBDIVISION: LOT = BLOCK ^ , FILING (UNIT) - <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Owner's Well Designation: wlycLi01 <br />must be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ? Zone 13 Easting: <br />STREET ADDRESS AT WELL LOCATION: - Northin : <br />4. GROUND SURFACE ELEVATION ?0$ 3.5 feet DRILLING METHOD lid ,M ,r,• At+? t wfrr <br />DATE COMPLETED e. lot l TOTAL DEPTH Ocl feet DEPTH COMPLETED 16 cf feet <br />5. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft <br />Depth Type Grain Size Color Water Loc. (o. 5 <br /> <br /> <br /> 7. PLAIN CASING: <br /> OD (in) Kind Wall Size (in) From (ft) To (ft) <br /> 4,5 V G a.25 4-1c. + <br /> - <br />4. 5 Pya 0.25 /t2 4 10 <br /> <br /> <br /> PERFORATED CASING: Screen Slot Size (in): 0.032 <br /> 4.5 PVC o.zs 64 104- <br /> <br /> <br /> <br /> 8. FILTER PgCK: 9. PACKER PLACEMENT: <br /> Material $t t[n- 54A4 Type '-' <br /> Size R-11 w+ <br /> Interval -604- <br />--- <br />Depth <br /> 0. GROUTING RECORD <br /> Material Amount Density Interval Placement <br />Remarks: t? o,.-e- ,n o<...o wecn <br /> <br />ba?o4i r&G4V-1 i$rJr <br />2-1 3b 0- ti Rz s - <br /> <br />11. DISINFECTION: T e Amt. Used '--' <br />12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD ?•? ?a• <br />Static Level 74.23 ft. Date/Time measured: 2 2 8 t Production Rate O,,Z gpm. <br />Pumping Level Datelrime measured 3 2 ll 9 Test Length (hrs) <br />Remarks: !taT tft." Or.w e? S Ka e- , : U-C-, <br />13. 1 have read the statements mad herein and know the ,tents thereof, and they are true to my knowledge. This document Is signed and certified in <br />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 <br />section 37-91-106 1 e , C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license. <br />Company lame: ) // <br />ar y.? 4-$ O avi?3 LNG Phone: <br />R70 .24L- p`1-2 O License Number: <br />2`} SS 1 <br />l <br />Mailing Address: '1 5 do ,"4,e- 4,-- 34-z> G -4 J" -6-i GO $4 O to <br />Signature: Print Name and itle <br />t' r i?s..? Pr 1, Date <br />U ??