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CONSTRUCTION AND TEST REPORT <br />OFFICE OF THE STATE ENGINEER <br />Room 818. Deriver. CO 80203 <br />Maui (303) 866 -3581 <br />^ + -us <br />For Moe Use Only <br />RECEIVED <br />UUN 1 5 2010 <br />WATER RESuLnCES <br />STATE ENGINEER <br />COLO. <br />WELL <br />FORM NO. <br />GlA - 31 STATE OF COLORADO, <br />0412005 1313 Sherman SL, <br />Phone — Info (303) 813587 <br />Fax ( 866 -3589 <br />1. �- 0 �� /2 r----, <br />2 WELL OWNER iNFORYATION • <br />NAME OF WELL OWNER: COCO1Pr9 ■80� of e491/4 CG 1 om•6eS <br />MAIUNG ADDRESS: / O. <br />go x J09'5 <br />STATE cO ZIP CODE:$ /Qd, <br />CITY: rR 14 4 . <br />TELEPHONE NUMBER: ( ) <br />3. WELL LOCATION <br />DISTANCES <br />SUBDIVISION: <br />Optional GPS <br />must be metros, <br />STREET ADDRESS <br />AS DRILLED: <br />FRO61 SEC. LINES: <br />4/e 1/4, /(!G <br />.r.38 ft. <br />1(4. Sec. <br />from rid <br />3 , Twp. <br />• <br />. ® N or ❑ S. <br />line and , qg Y <br />Range R 7 ❑ E or <br />at w <br />section tune. <br />R from J <br />, FIUNG <br />E or ❑ W <br />(UNIT) <br />Well OesigrtaIion: <br />N or II S section <br />LOT BLOCK <br />be UM, Units <br />12 or Q Zone 13 <br />Location: GPS Una must use the following settings' <br />Datum must be NAD83. Una most be set to <br />AT WELL LOCATION: <br />t Format <br />true N. II <br />must <br />Zone <br />Owners <br />Easfang: <br />Northing: <br />4. GROUND SURFACE ELEVATION <br />DATE COMPLETED 06 , C <br />6 7.r <br />feet / DRILLING <br />DEPTH DO feet <br />METHOD m m.L ; Ariay <br />• O TOTAL <br />DEPTH COMPLETED 5 feet _ <br />5. GEOLOGIC LOG: Co o <br />,-Mi hp f • <br />S. HOLE DIAM (in_) From (ft) To (ft) <br />Depth <br />,e <br />Type <br />Grain Size <br />Con <br />Water Loc. _ <br />/ n W <br />Wan <br />, <br />0 Y 0 <br />7 7 <br />L/ O O <br />7. PLAIN <br />OD <br />� <br />.4"s <br />CASING: <br />(m) Kind <br />sfPp/ <br />.C'SO A <br />Size (in) Foram (ft) To (ft) <br />/RA f / 40 <br />. -Teel ritlfo '- / ,47/ <br />PERFORATED <br />AO <br />NG: Screen Slot Size (in): <br /># 7Ci u. S/ 0 <br />O.O, /O <br />SI` D <br />• <br />8. FILTER <br />Material <br />Sire <br />Intel <br />PACK A <br />sca <br />9. PACKER <br />Type <br />CEMENT: <br />f ltiv w..+C 7 ,11 . <br />.?S — <br />l 7 <br />10. <br />GROUTING RECORD <br />Amount <br />; LC-0 <br />Density <br />-7 <br />'7./ <br />Interval <br />s30-6o0 <br />e' -1.fZ <br />Ptacernent <br />ideolle <br />Material <br />Remarks: <br />/ <br />rein <br />-4 -. <br />Aarte <br />11. DISINFECTION: T - 1 AmL Used y OZ <br />j-(--T <br />12. WELL TEST <br />TESTING METHOD <br />Static Level <br />DAT Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test <br />Q i P ['emptolC91 <br />D ft. Datefriime <br />measured: <br />ff ire measured <br />4 • / • it, . Production <br />Rate <br />(hrs) <br />,4" gpm. <br />Pumping Level <br />Remarks: <br /><`d 0 IL Dat <br />46. / /o , Test Length <br />at . <br />. <br />13. I have read the slatenterds made herein and Iauow due contents thereof. and They are hue to my knowledge. This document Is signed and certified in <br />accordance wdtt Rule 17.4 of the Wider Well Consetrrtion Rules. 2 CCR 402-2. Me Wang d a document that contains false statements is a viatadan of <br />section 37-91-108(1Xe). CRS.. and is punishable by tires up to 65000 aridity 'evocation of the contracting Weasel <br />0 0 .r if/�pL(fft <br />/ ar /l,�l Tile • <br />)sv r2t1 U. co_ LJd.{ ‘ <br />� (9 ) e V - ?CI /o 1 <br />_ <br />I t y <br />Mailing ' P G. BUY <br />. --eiy. t/� /� ✓ <br />iPeS tt v./A. i''3 . tae le /.., <br />l <br />1 ,f"• /o <br />