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FORM NO. GWS-31 04/2005

WELL CONSTRUCTION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 818, Denver, CO 80203 Phone ­ Info (303) 866-3587 Main (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us

For Office Use Only

1. WELL PERMIT NUMBER: 2. WELL OWNER INFORMATION NAME OF WELL OWNER: MAILING ADDRESS: CITY: TELEPHONE NUMBER: ( STATE: 1/4, 1/4, ft. from Sec. N or ZIP CODE: , Twp. S section line and , LOT N or S, Range E or W

)

3. WELL LOCATION AS DRILLED: DISTANCES FROM SEC. LINES: SUBDIVISION:

, BLOCK

Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Zone 12 or Zone 13 must be meters, Datum must be NAD83, Unit must be set to true N, STREET ADDRESS AT WELL LOCATION: 4. GROUND SURFACE ELEVATION DATE COMPLETED 5. GEOLOGIC LOG: Depth Type Grain Size feet TOTAL DEPTH Color Water Loc.

ft. from E or W section line. , FILING (UNIT) Owner's Well Designation: Easting: Northing:

DRILLING METHOD feet DEPTH COMPLETED 6. HOLE DIAM (in.) From (ft)

feet To (ft)

7. PLAIN CASING: OD (in) Kind Wall Size (in) From (ft) To (ft)

PERFORATED CASING: Screen Slot Size (in):

8. FILTER PACK: 9. PACKER PLACEMENT: Material Type Size Interval Depth 10. GROUTING RECORD Material
Remarks:

Amount

Density

Interval

Placement

11. DISINFECTION: Type Amt. Used 12. WELL TEST DATA: Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test. TESTING METHOD Static Level ft. Pumping Level ft. Remarks: Date/Time measured: Date/Time measured , Production Rate , Test Length (hrs) gpm. .

13. I 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 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 section 37-91-108(1)(e), C.R.S., and is punishable by fines up to $5000 and/or revocation of the contracting license.]

Company Name: Mailing Address: Signature:

Phone: ( ) Print Name and Title

License Number: Date

Rev 04/2005

INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT
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. 2. 3. Complete the Well Permit Number in full. Fill in Name and Mailing Address of Well Owner where correspondence should be sent. 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 108th th th th 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. 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) Provide the diameters of the drilled borehole. 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. Indicate the material and size of filter pack (e.g. sand, gravel, etc.) and the interval where placed. Indicate the type and setting depth for any packers installed. 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. Record the type and the amount of disinfection used, how placed, and the length of time left in the hole. 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. 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.

5.

6. 7. 8. 9. 10.

11. 12.

13.

Submit completed report to: State of Colorado, Office of the State Engineer, 818 Centennial Bldg., 1313 Sherman St., 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 (970-2471845), 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.