2013-04-11_REVISION - C1992080 - Laserfiche WebLink

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6. Provide the diameters of the drilled borehole INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT Rev 10/2011 The report must be typed or printed in BLACK OR BLUE INK. All changes on the form must be initialed and dated. Attach additional sheets if more space is required. Each additional sheet must be identified at the top by the well owner's name, the permit number, form name /number and a sequential page number Report depths in feet below ground surface. This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State Engineer Photocopy reproductions must retain margins and print quality of the original form. The original form must be submitted to the State Engineer's Office within 60 days after completing the well or 7 days after the permit expiration date, whichever is earlier. A copy of the form must be provided to the well owner. ITEM INSTRUCTIONS: (numbers correspond with those on the front of this form) 1 Complete the Well Permit Number in full. 2. Fill in Name and Mailing Address of Well Owner where correspondence should be sent. 3 Complete the blocks for the actual location of where the well was drilled If the owner has more than one well serving this property, provide the identification (Owner's Designation) for this well For wells located in subdivisions, the name, lot, block, filing, and street address must also be provided. An option to providing distances from section lines is to provide an accurate GPS location in GPS format. The required GPS unit settings must be as indicated on this form Colorado contains two (2) UTM zones. Zone 13 covers most of Colorado. The boundary between Zone 12 and Zone 13 is the 108 Meridian (longitude). West of the 108` Meridian is UTM Zone 12 and east of the 108 Meridian is UTM Zone 13. The 108 Meridian is approximately 57 miles east of the Colorado -Utah state line On most GPS units, the UTM zone is given as part of the Easting measurement, e.g 12T0123456 Check the appropriate box for the zone 4. Report the ground surface elevation in feet above sea level if available. This value may be obtained from a topographic map Describe the drilling method used to construct the well and the date completed. Indicate the total depth and the actual completed depth of the well. 5. Fully describe the materials encountered in drilling Do not use formation names unless they are in conjunction with a description of materials. Examples of descriptive terms include' Type — sandstone, sand, etc. Grain size — Boulders, gravel, sand, silt, clay, etc. Color — All materials, most critical in sedimentary rock Water Location — Depth when water is encountered (if it can be determined) 7 The outside diameter, kind, wall thickness, and interval of plain and perforated casing lengths must be indicated For perforated casing, the screen size must be indicated 8 Indicate the material and size of filter pack (e g. sand, gravel, etc.) and the interval where placed 9 Indicate the type and setting depth for any packers installed. 10. The material, amount, and interval of the grout slurry must be reported. Density may be indicated as pounds per gallon, gallons of water per sack, total gallons of water used, or number of sacks used, etc. Specify the grout placement method, i.e. tremie pipe or positive placement The percentage of additives mixed with the grout should be reported under remarks in item 5. 11. Record the type and the amount of disinfection used, how placed, and the length of time left in the hole 12. Report well test data as required by Rule 10 7 Spaces are provided to report all measurements made during the test The report should show that the test complied with the provisions of the rules If a test was not performed explain when it will be done. If available, report clock time when measurements were taken 13. Fill in Company Name and Address of Contractor who constructed the well. The licensed contractor responsible for the construction of the well must sign the report. Submit completed report to State of Colorado, Office of the State Engineer, 818 Centennial Bldg , 1313 Sherman St, Ste 821, Denver, CO 80203 IF YOU HAVE ANY QUESTIONS regarding any item on this form, please call the Division of Water Resources Ground Water Information Desk (303- 866- 3587), or the nearest Division of Water Resources Field Office located in Greeley (970- 352 - 8712), Pueblo (719 -542- 3368), Alamosa (719- 589 - 6683), Montrose (970- 249 - 6622), Glenwood Springs (970- 945 - 5665), Steamboat Springs (970- 879 - 0272), or Durango (970- 247 - 1845), or refer to our web site at http / /www.water.state co us for general information, additional forms, and access to state rules and statutes.