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FORM NO. � <br />�t1190 <br />PUMP INSTAL.l.AMON AND TEST SORT <br />I MTE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />fw omcs use 0* <br />PMIVED <br />1. <br />WELL PERMIT NUMBER F -R <br />9921w <br />2. <br />OWNER NAMES) William A. Rodman <br />Mailing Address 3rl3'--VF 3 13'--VF Street <br />RM <br />E <br />City, St. Zip Greeley. CO 806 <br />Phone ( 303) 353-2311 <br />i r -� G • 93 <br />3. <br />UVELL LoCAngN AS DRILLED: BE 1/4 SE 114, Sec. 35 Twp. 6 N . Range 66 W <br />DISTANCES FROM SEC, LINES: <br />15130 ft. from a Sec. line. and s ft. from �S= ate. <br />SUBDIVISION: LOT BLOCK FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />4. <br />PUMP DATA: TM jQg alkle Instaiiadon Completed 12-12721 <br />Pump Manufacturer Gould Pump Model No. <br />Design GPM 25 __ at RPM HP .11 _rte Volts 2, . Full oad Amps <br />Pump Intake Depth - 25 - Feet, Drop/Column Pipe Size Ii �IrOw, l9nd <br />ADDITIONAL, INFORMATION F PS GRgM T <br />TURBINE DRIVER TYPE: 0 sectric Engine El Other <br />Design Head feet, Number of Stages Shaft size Inches. <br />5. <br />OTHER EQUIPMENT: <br />Airline Installed Q Yes [M No, Orifloe Depth ft. Monitor Tube Installed ❑ `des [!]No, Depth ft. <br />Flow Meter Mfg. Done Meter Serial No <br />Meter Readout Gallons, ❑ Thousand Gallons, ❑ Acre feet, ❑ Beginning Reading <br />a <br />TEST Check boor If Test data Is submitted on Supplemental Form, <br />Date <br />Total Weil Depth 361 Time <br />Static Level 81 Rate (GPM) 35 Opea Disclfine <br />Date Measured 12- 1'4-43 Pumping LA ,V <br />7. <br />DISINFECTION: Type H.T.H. Amt Used is <br />a. <br />Water Quality analysis avallabie. ❑ Yes No <br />Q. <br />Remarks <br />0. 1 have read the statements trade herein and know the contents thereof, and that they are tree to my knowledge <br />(Pursuant to Section 24- 4-104 (13)(a) C.R.S., the making of faire statements herein constitutos perjury in the secon <br />degree and is punishable as a dos 1 misdemeanor.] <br />CONTRACTOR Lash Drilling. Inc. phone (=J $ -2868 ___ Lie. No. 21 <br />Mailing Address P.O. Box 56 Ault CO 80610 <br />Nam /Title (Please type or print) <br />Signature <br />Date <br />Ddirin D. Leab, Jr. President <br />12 -16-93 <br />