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FORM NO. <br />GWS-31 <br />02/20b5 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 />h <br />Fax 303 866-3589 For Office Use Only <br /> <br />RECEIVED <br />/ <br />WELL PERMiTNUMBER: to/ LI) y JUL 1 1 2005 <br />. WELL OWNER INFORMATION _ <br />NAME OF WELL OWNER: <br />WATER RESOUPCES <br />STATE ENGINEER <br />MAILING ADDRESS: COLO. <br />CITY: L STATE: ZIP CODE: a/ <br />TELEPHONE NUMBER: / O - <br />tZ <br />WELL LOCATION AS DRILLED: NE 1/4, Sec. gf, Twp. }1 K N or [IS, Range -L ®E or [] W <br />_W114, <br />DISTANCES FROM SEC. LINES: , i 00 it. from M N or ? S section line and !90 ft. from ? E or o 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 must Eastin 3?P?'O rf / <br />be meters, Datum must be NAD83, Unit must be set to true N, ? Zone 12 or ® Zone 13 9' ' <br />STREET ADDRESS AT WELL LOCATION: Northin : `116,2,5-Vol <br />GROUND SURFACE ELEVATION 3 `1 feet DRILLING METHOD <br />DATE COMPLETED TOTAL DEPTH/q feet DEPTH COMPLETED /z feet <br />. GEOLOGIC LOG: 6. HOLE DIAM in. From ft To ft <br />Depth Type Grain Size Color Water Loc. D 7' <br />- av-l Sf %y /4'7" 39' <br />/ <br /> 7. PLAIN CASING: <br />/-2o Yo, SALaL Kind Wall Size (in) From (ft) To (ft) <br />OD (in) <br /> I <br /> <br /> y ,• vc ?, yv /3 , i yam/ <br /> <br /> PERFORATED CASING: <br />cre <br />e <br />n <br />Slot Si <br />S <br />e (in): <br /> z <br />? <br />? <br />? <br />? <br />? <br /> <br /> <br /> I <br /> 8. FILTER PACK: . PACKER PLACEMENT: <br /> Material IV 1W Type <br /> Size <br /> Interval Depth <br /> 0. GROUTING RECORD <br /> Material <br />Amount Density Interval Placement <br />Remarks: ¢ <br /> <br /> <br />1. DISINFECTION: Type f/ jy {O-p le Amt. Used OZ , <br />!. WELL TEST DATA: Checpk b?oxxiif Test Data is submitted on Form Number GWS 39 Supplemental Well Test. <br />-ESTING METHOD l a , ?p K <br />static Level -L2 <br />ft. Date Time measured: `/ "Zf?' OS /7_ -,?Y, Production Rate .7-9' gpm. <br />lumping Level N/µ ft. Date/Time measured OJ Test Length (hrs) _ 3 <br />temarks: Va?RbCts1?.7 .onT' S- <br />?. 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 <br />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 <br />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. <br />M ryame <br />Many rK 6vt.i1itAc,Tryc. Phone: <br />% S2 k S License Number: <br />7 <br />tailing Address: /yy y I4w' 02f s j/?c. a*_- /yy <br />ignature I?S /7 Prin0ame and Title nn q? Date <br />j(e H 2? is v C A? OAS PL . y'??-LL1