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FORM NO. PUMP INSTALLATION AND TEST REPORT For Office Use onlyGWS -32 <br />10194 STATE OF COLORADO, OFFICE OF THE STATE ENGINEER RECEIVED <br />1. WELL PERMIT NUMBER c i_ D 8 MAY 11 2000 <br />2 OWNER NAMES) 9 0 % Lt///Gtrn <br />Mailing Address 56 <br />wrfEfl HEscx)RcES <br />STATE ENGINEER <br />City, St. zip / - Cog <br />COLO <br />Phone { ) <br />3. WELL LOCATION AS DRILLED: _JJ &J 1/4 _/F: 1/4, Sec. Twp.` Range 26,0a <br />DISTANCES FROM SEC. LINES: <br />ft. from /UO r -M Sec. line. and _/ ft. from a3 -' Sec. line. <br />LMrso teast or WEW <br />SUBDIVISION: LOT BLOCK FIUNG(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />PUMP DATA. Type e Installation Completed4. <br />Pump Manufacturer n Pump Model No. <br />Design GPM /,j at RPM 2!2s -n HP ` Volts 0 30 , Full Load Amps Z <br />Pump Intake Depth fesO Feet, Drop/Column Pipe Size__ r <br />Inches, Kind 3Ch g _ P(/G <br />ADDMONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM: <br />TURBINE DRIVER TYPE: Electric Engine Other <br />Design Head feet, Number of Stages , Shaft size inches. <br />5. OTHER EQUIPMENT: <br />Airline Installed = Yes No, Orifice Depth ft. Monitor Tube Installed Yes No, Depth ft. <br />Flow Meter Mfg. ; Meter Serial No. <br />Meter Readout Gallons, Thousand Gallons, Acre feet, Beginning Reading <br />6. TEST DATA: Check box if Test data is submitted on Supplemental Form. <br />Date /-/- } <br />Total Well Depth' Time ,n <br />Static Level 3 2' Rate (GPM) <br />Pumping Lvi. Date Measurednny <br />7. <br />rr <br />DISINFECTION: Type or- - Cil 101-1 rte, Amt. Used C <br />8. Water Quality analysis available. Q Yes No <br />9. Remarks <br />0. 1 have read the statements made herein and know the contents thereof, and that they are true to my knowledge <br />Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second <br />degree and is punishable as a class 1 misdemeanor.) <br />CONTRACTOR WAYNE'S PUMP SERVICE Phone (970) 484-8588 Lie. No1292 <br />Mailing Address P.O. Box 906 • LaPorte, CO 80535 <br />Narnei7itle (Please type or print) Signa Date <br />beme-+-'Ios 110s ('owner) 1- -31 -0 0