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FORM NO. <br />GWS -31 <br />10/2011 <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St., Ste 821, Denver, CO 80203 <br />Main (303) 866 -3581 Fax (303) 866 -3589 <br />For Office Use Only <br />1. WELL PERMIT NUMBER: <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: <br />MAILING ADDRESS <br />CITY: STATE ZIP CODE <br />TELEPHONE NUMBER ( ) - <br />3. WELL LOCATION AS DRILLED: 1/4, 1/4, Sec. Twp • N or • S, Range • E or • W <br />DISTANCES FROM SEC. LINES: ft. from • N or ■ S section line and ft from • E or • W section line <br />SUBDIVISION: LOT BLOCK FILING (UNIT) <br />Owner's Well Designation. <br />Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units <br />Easting. <br />must be meters, Datum must be NAD83, Unit must be set to true N, • Zone 12 or • Zone 13 <br />STREET ADDRESS AT WELL LOCATION Northing <br />4. GROUND SURFACE ELEVATION feet DRILLING METHOD <br />DATE COMPLETED TOTAL DEPTH 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 />7. PLAIN CASING. <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />PERFORATED CASING Screen Slot Size (in) <br />8. FILTER PACK <br />Material <br />9. PACKER PLACEMENT <br />Type <br />Size <br />Interval <br />Depth <br />10. GROUTING RECORD <br />Material Amount Density Interval Placement <br />Remarks: <br />11. DISINFECTION Type <br />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 <br />Static Level ft. Date/Time measured: Production Rate gpm. <br />Pumping Level ft. Date/Time measured Test Length (hrs) <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 Well Construction Rules, 2 CCR 402 -2. [The filing of a document that contains false statements is a violation of <br />section 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 />Phone <br />( ) - <br />License Number <br />Mailing Address: <br />Signature. <br />Print Name and Title <br />Date <br />