Laserfiche WebLink
roxM xo. <br />6WS32 <br />sizoo3 .PUMP INSTALLATION AND TEST REPORT <br /> <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER Fo. oxiee u5a ony <br />1. WELL PERMff NUMBER <br />2 OWNER NAME(S) <br /> Mailing Address <br /> City, St. Zip <br /> Phone ( ) <br />3. WELL LOCATION AS DRILLED: 1/4 1/4, Sec. Twp. ,Range <br /> DISTANCES FROM SEC. LINES: <br /> ft. from Sec. line. and ft, from Sec. line. <br />~T <br /> SUBDIVISION: LOT_BLOCK FILING(UNIT) <br /> STREET ADDRESS AT WELL LOCATION: <br />4. PUMP DATA: Type Installation Completed <br /> Pump Manufacturer Pump Model No. <br /> Design GPM at RPM , HP , Volts ,Full Load Amps <br /> Pump Intake Depth Fee[, Drop/Column Pipe Size Inches, Kind <br /> ADDITIONAL 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 'rf Test data is Submitted on Supplemental Form. <br /> Date <br /> Total Well Depth Time <br /> Static Level Rate (GPM) <br /> Date Measured Pumping Lvl. <br />7. DISINFECTION: Type Amt. Used <br />8. Water Quality analysis available. ^Yes ^ No <br />9. Remarks <br /> <br /> <br /> <br /> <br /> <br /> <br />Q I 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 secon <br />degree and is punishable as a class 1 misdemeanor.] <br />CONTRACTOR Phone ~~ Lic. No. <br />Mailing Address <br />Name/Title (Please type or print) Signature Date <br />