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1 ~' <br />1D°M No' l CONSTRUCTION ANP JCL°CD^~ -~ <br /> <br />~~' STATE OF COLORADO, OFFICE OF TF <br />cvsar he S rlv IIIIIIIIIIIIIIIIIII <br />1. WELL PERMfT NUMBER G V h W- l3 C -so For office Use ony <br />2 OWNER NAME(S) Gr ~ A o le. Crock 4' yi c~.Ot Golol I1;h;1wCo, <br />Mailing Address P O dox 191 ~ <br />City, St. Zip V:~ _r CD RO 860 <br /> Phone (7~ ) G g9 - yO <br />3. WELL LOCAT[ON AS DRILLED: 5 ~ 1 /4 N ~ t/4, Sec,~Z Twp.~~~ S ,Range 6 4 (,l) <br />DISTANCES FROM SEC. LINES: <br />ft. from Sec. line. and ft. from Sec. line. OR <br />~~+)" 4' <br />SUBDMSION: LOT_BLOCK FILING(UNfI) <br />STREET ADDRESS AT WELL LOCATION: <br />4. GROUND SURFACE ELEVATION ld /58,5 ft. DRIWNG METHOD ConJexl~:or, a~ A ~ r )')a MrneX' <br />DATE COMPLETED I Z Zo zooo ,TOTAL DEPTH ft. DEPTH COMPLETED ft. <br />5. GEOLOGIC LOG: <br />Depth Description of Material (type, Size, Color, Water Location) & HOLE DIAM. (in.) From (ft) To (ft) <br />~~f (~ ~i~ <br />See, A~acl, <br /> <br /> 7. PLAIN CASING <br /> OD (n) Kind WaII Size From(ft) To(ft) <br /> S ~' S t~wl _Q_ ZA <br /> r/'" YVG S I. Vd D 3U <br /> <br /> <br /> PERF. CASING: Screen Slot Size: ZO <br /> ~'~ V G Sc 1, +[~ ~~ o <br /> <br /> <br /> <br /> <br /> S. FILTER PACK: 9. PACKER PLACEMENT: <br /> Material 5",1~~ So~r,c~ Type <br /> Size <br /> Interval 2 6 -,S~ Depth <br /> <br /> 10. GROUTING RECORD: <br /> Material our1~ Density Interval Placement <br />REMARKS: R„~1~ SOS p-z6 <br /> <br />1 DISINFECTION: Type loon v Amt. Used <br /> WELL TEST DATA: ^ Check box if Test Data is submitted on Form No. GWS 39 Supplemerrtal Well Test. <br />TESTING METHOD <br />Static Level ft. Date~me measured ,Production Rate gpm. <br />Pumping level ft. Date~me measured ,Test length (hrs.) <br />Remarks <br />3. I have read the statemerrta made herein and know the eomerrts thereof, and that they are true to my knowledge. [Pursuant to Seetion 244104 (13)(a) <br />C.RS., the making of false stetemenb herein eonstihrtee perjury in the second degree and is punishable ae s clear 1 m'udemaanor.] <br />CONTRACTOR K '(~ Phone (~ Lic. No. <br />Mailin Address • O. oft o9 an,set l`'fT- 5 7 8 <br />Name/Trtle (Please type or prirrt) <br />.Scot}, A . Le..a;51 r1ol.a~c. ; Eti~ d Va;rs Signature Date <br />