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FORM R0. <br />NS'32 <br />ttr9o / PUMP INSTALLATION AND TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER F« o~. ua. ony <br />_ _ ~ <br />, ; .` : ~~' <br />1. WELL PERMff NUMBER 161244 JUN17~92 <br /> <br /> OWNER NAME(S) Julin Silva <br /> <br />Mailing Address 19800 Co. Rd. 21.4 <br />CRy, St. Zip Yestnn~olnradn A100t ~...~,-, <br />wxrtn ti <br />ctA?[ F' ~'~' ' <br /> Phone ( 1 ) 868- <br />3. WELL LOCATION AS DRILLED: Hld 1/4 NE 1/4, Sec.~~Tvvp. 3~ S , Range_¢~ Y <br /> DISTANCES FROM SEC. LINES: <br /> ~_ ft from N Sea line. and 1990 R from E Sec. Tine. <br />n«m « .aah) we « wvaq <br /> SUBDMSION: LOT BLOCK FILING(UNfn <br /> STREET ADDRESS AT WELL LOCATION: <br />4. PUMP DATA: Tyoe Sut~eraible Ins'.a!Iazicn Co^ple!ed 4/19/92 <br /> Pump Manufacturer Air Motor Pump Model No. Uakaoxn <br /> Design GPM U at RPM , HP , Voks1'a0 ,Full Load Amps 8.0 <br /> Pump Intake Depth Feet, Drop/Column Pipe S¢e 1 Inches, IGnd PVC Sch. 80 <br /> ADDfiIONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM: <br /> TURBINE DRNER 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 fL it <br /> Flow Meter Mtg. Meter Serial No. <br /> Meter Readout ^ Gallons, ^ Thousand Gallons, ^ Acre feet, ^ Beginning Reading <br />. TEST DATA: ^ Check bout if Test data is submitted on Su plemerttal Form. <br />Date 4 1 2 <br /> Total Well Depth 80' Time lr'10 to 4~'a0 <br /> Static Level <br />Rate (GPM) <br />3 <br /> Date Measured Pumping Lvi. <br />41 <br />92 <br />7. DISINFECTION: Type IiT1i Amt. Used 4 tableenoont: <br />8. Water Quality analysis available. ^ Yes ®No ___ _ __ <br />9. Remarks Installed used poop furaiahed by otmer. Model atuber xas ~ <br /> aot ledaeable. <br /> <br /> <br /> <br /> <br /> <br />~. I have read the statements made herein and know the contents thereof, and that they aze true to my knowledge. <br />[Pursuant to Section 24~-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the secon <br />degree and is punishable as a class 1 misdemeanor.] <br />CONTRACTOR Snyder Bri111nA Contractor Phone 7( 19 1 846-2145 Lic. No.~. <br />Mailing Address-~0. Box 5"i. R`tinidad. Co. 81082 <br />Jame~tle (Please type or print) <br />' Signature Date <br />l'larion M, Snyder - Oxner 6 15 92 <br /> <br />1 <br /> <br />0 <br />