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�• FpRM NO. ✓ .PUMP iNST/ NTION AND TEST REPORT r For office UM,An�:-;4 P✓� <br /> Gk'S <br /> 11/ STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br /> T I. WELL PERMIT NUMBER 038095-F %NJ 3V <br /> 2. OWNER NAMES) A & G Partnership WA.ra►'a uncEs <br /> Mailing Address 3324 E-1/4 Road <br /> City, St. Zip Clifton, CO 81520 <br /> Phone ( 303 ) 242-8134 <br /> SE174 SW1 4, Section 5 and <br /> 3. WELL LOCATIO,AS DRILLED: NE 1/4_ NW 1/4,Sec.--L.- Twp. 1 � , Range 1 W. <br /> DISTANCES FROM $EC. LINES: <br /> ft, from ---- Sec, line. and ----- ft. from ---- Sec. line. <br /> TnVFor SEK or VOMM <br /> SUBdNISION: N/A I LOT BLOCK FILING(UNIT) <br /> STREET ADDRESS AT WELL LOCATION: None <br /> 4. PUMP DATA:Type Self Priming. Centrifugal* Installation Completed yaauary 7, 1991 <br /> Pump Manufacturer QQrman-RuPp , .— Pump Model No. 16c2-5034 <br /> Design GPM 2¢0 at RPM 2000 , HP_ 70 , Volts b}esel, Full Load Amps Diesel . <br /> Pump Intake DepthUg ox.2 eet. Drop/Column Pipe Size 6 Inches, Kind Rigid Rubber <br /> *See attached <br /> ADDITIONAL INF0RMAT10N FQA PUMP GREATER„IHAT 50 GPM: Specification Data Sheet <br /> TURBINE DRIVER TYPE: ❑ Electric ® Engine ❑Other <br /> Design Head max. 15 0 feet, Number of Stages One Shaft size Unknowninches. <br /> 5. OTHER EQUIEjutgNT: <br /> Airline Installed DYes®No, Orifice Depth fL Monitor Tube Installed ❑Yes ]No, Depth ft. <br /> Flow Meter Mfg.No meter Meter.-Serial No. N/A <br /> Meter Readout❑Gallons, ❑Thousand Gallons, ❑Acre feet, ❑ Seginning Reading <br /> 6. TEST DAT Check box If Test data is submitted on Supplemental Form. <br /> Date <br /> Total Well Depth N A Time <br /> Static Level Rate (GPM) <br /> Date Measured Pumping LvI. '� <br /> 7. DISINFECTION: Type None Amt. Used <br /> 8. Water Quality analysis available. ❑ Yes FLI No <br /> 9, Remarks The subject well permit is for a gravel pit. The pump described <br /> above is. a temporary portable pump used for dewater ng and/or dust <br /> suppression, and is located on the rim or Fa ot the pit. A lose is — <br /> extended from the R-Limp to the water in the 2it, to allow water to be <br /> _Rumned fxoM the git. Q pumps will be permanently installed in or <br /> around the pit, nor will Concrete sings or rather „Vermanent pumping <br /> -r-tr.1jct iirrssa ha S -.A 1 1 PP3_ —_ <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 244-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the seconc# <br /> degree and is punishable as a class 1 misdemeanor.] <br /> CONTRACTOR OWNER Phone (_) Lic. No. <br /> Mailing Address <br /> Name/Title (Please type or print) Signatur Date <br /> Alah' Parkerson General Partne 11/10/92 <br />