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FORM NO <br />Gws-31 <br />04/2005 <br />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 http :ilwww.water.state.co,us <br />For Office Use Only <br />ECEIVED <br />FEB 2 3 2009 <br />R_p� <br />STATE <br />1. WELL PERMIT NUMBER: 67426E <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: DALBO INC <br />MAILING ADDRESS: PO BOX 1168 <br />CITY: VERNAL STATE: UT ZIP CODE: 84078 <br />TELEPHONE NUMBER: (435) 789-0743 <br />3. WELL LOCATION AS DRILLED: NW1 /4, NE1 /4, Sec. 1, Twp. 1 Cl. N or ❑ S, Range 97 • E or ►_ W <br />DISTANCES FROM SEC. LINES: 900 ft. from ■4 N or • S section line and 1500 ft. from ►_i E or • W section line. <br />SUBDIVISION: , LOT , BLOCK FILING (UNIT) <br />Owner's Well Designation: <br />Format <br />Optional GPS Location: GPS Unit must use the following settings: must be UTM, Units <br />be Datum NAD83, Unit be to true N, • Zone 12 • Zone East ng: <br />must meters, must be must set or 13 <br />STREET ADDRESS AT WELL LOCATION: Northing: <br />4. GROUND SURFACE ELEVATION feet DRILLING METHOD AIR ROTARY <br />DATE COMPLETED 12 -20-08 TOTAL DEPTH 50 feet DEPTH COMPLETED feet <br />5. GEOLOGIC LOG: <br />6. HOLE DIAM (in.) From (ft) To (ft) <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loc. <br />10 0 20 <br />6.5 20 50 <br />0-20 <br />TOPSOIL <br />FINE <br />BROWN <br />20-25 <br />GRAVEL <br />COURSE <br />GREY <br />22 <br />25-50 <br />SANDSTONE <br />FINE <br />GREY <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />7 STEEL .188 -1 20 <br />5 PVC .248 40 50 <br />PERFORATED CASING: Screen Slot Size (in): .030 <br />5 PVC .248 20 40 <br />8. FILTER PACK: <br />Material <br />9. PACKER PLACEMENT: <br />Type <br />Size <br />Interval <br />Depth <br />_ _____ _ _ ______ <br />10. GROUTING RECORD <br />Material Amount Density Interval Placement <br />CEMENT 270 LBS 0 -20 VIBRATE <br />Remarks: <br />11. DISINFECTION: Tye HTH <br />Amt. Used 1 CUP <br />_ <br />12. WELL TEST DATA 0 Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />TESTING METHOD PUMP <br />Static Level 22 ft. Date/Time measured: 12 -20-08 Production Rate 5 gpm. <br />Pumping Level 40 ft, Date/Time measured , Test Length (hrs) 2 . <br />Remarks: <br />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 <br />accordance with Rule 17.4 of the Water Weil Construction Rules, 2 CCR 402 -2. (The filing of a document that contains false statements is a violation of <br />sectton 37 - 91 - 108(1)(e), C.R.S., and is punishable by fines up to $5000 and/or revocation of the contracting license.] <br />Company Name: <br />WATER PUMP SUPPLY AND SERVICE <br />Mailing Address: PO BOX 24 MEEKER CO 81641 <br />Signature: � Print Name and Title <br />I TRAVIS DAY C)WNFR <br />Phone: <br />(970)878 -0165 <br />License Number. <br />1345 <br />E Date <br />1 1 119 2/}(19 <br />