DWR_1002584

• Permitno: 260909
• Receipt Number: 9302744
• Document Type - Well Permit: Well Construction
• Annotated?: No

FORM NO.
GWS-31
02/20b5 WELL CONSTRUCTION AND TEST REPORT
-STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 818, Denver, CO 80203
Phone - Info [phone] Main [phone]
hftp://www.water.state.co.us
Fax [phone] For Office Use Only

RECEIVED
/
WELL PERMiTNUMBER: to/ LI) y JUL 1 1 2005
. WELL OWNER INFORMATION _
NAME OF WELL OWNER:
WATER RESOUPCES
STATE ENGINEER
MAILING ADDRESS: COLO.
CITY: L STATE: ZIP CODE: a/
TELEPHONE NUMBER: / O -
tZ
WELL LOCATION AS DRILLED: NE 1/4, Sec. gf, Twp. }1 K N or [IS, Range -L ®E or [] W
_W114,
DISTANCES FROM SEC. LINES: , i 00 it. from M N or ? S section line and !90 ft. from ? E or o W section line.
SUBDIVISION: LOT_, BLOCK_, FILING (UNIT) _
Owner's Well Designation:
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units must Eastin 3?P?'O rf /
be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ® Zone 13 9' '
STREET ADDRESS AT WELL LOCATION: Northin : `116,2,5-Vol
GROUND SURFACE ELEVATION 3 `1 feet DRILLING METHOD
DATE COMPLETED TOTAL DEPTH/q feet DEPTH COMPLETED /z feet
. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft
Depth Type Grain Size Color Water Loc. D 7'
- av-l Sf %y /4'7" 39'
/
7. PLAIN CASING:
/-2o Yo, SALaL Kind Wall Size (in) From (ft) To (ft)
OD (in)
I

y ,• vc ?, yv /3 , i yam/

PERFORATED CASING:
cre
e
n
Slot Si
S
e (in):
z
?
?
?
?
?

I
8. FILTER PACK: . PACKER PLACEMENT:
Material IV 1W Type
Size
Interval Depth
0. GROUTING RECORD
Material
Amount Density Interval Placement
Remarks: ¢

1. DISINFECTION: Type f/ jy {O-p le Amt. Used OZ ,
!. WELL TEST DATA: Checpk b?oxxiif Test Data is submitted on Form Number GWS 39 Supplemental Well Test.
-ESTING METHOD l a , ?p K
static Level -L2
ft. Date Time measured: `/ "Zf?' OS /7_ -,?Y, Production Rate .7-9' gpm.
lumping Level N/µ ft. Date/Time measured OJ Test Length (hrs) _ 3
temarks: Va?RbCts1?.7 .onT' S-
?. I have read the stete-ents ma herein and know the contents thereof, and they are true to my knowledge. This document is signed and
rifted in accordance with Rule 17.4 of the Water Well Construction Rules. 2 CCR 402-2. [The filing of a document that contains false
aternents is a violation of section 37-91-108 1 e , C.R.S., and is punishable b fines u to $5000 and/or revocation of the contracting license.
M ryame
Many rK 6vt.i1itAc,Tryc. Phone:
% S2 k S License Number:
7
tailing Address: /yy y I4w' 02f s j/?c. a*_- /yy
ignature I?S /7 Prin0ame and Title nn q? Date
j(e H 2? is v C A? OAS PL . y'??-LL1