2003-09-05_REVISION - M1986076 (2)

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INSTRUCTIONS FOR PUMP INSTALLATION REPORT The report must be typed or printed in BLACK INK. All changes on the form must be initialed and dated. Attach additional sheets if more space is required. Each additional sheet must be identified at the top by the well owner's name, the permit number, form namelnumber and a sequential page number. Report depths in feet below ground surface. This form may be reproduced by photocopy methods, or by computer generation with prior approval by the State Engineer, The original and one copy of this form must be submitted to the State Engineer's Office within 60 days after completing the well or 7 days after the permit expiration date, whichever is earlier. Another copy of the form must be provided to the well owner. If this form is submitted in conjunction with the Well Completion and Test Report, form number GWS-31, ONLY THE PERMIT NUMBER AND OWNER NAME NEED TO BE COMPLETED in items 1 and 2. Complete the Permit Number in full. 2. Fill in Name and Mailing Address of Well Owner where correspondence should be sent. 3. Complete the blocks for the actual location of the wall. For wells located in subdivisions the lot, block and subdivision information must also be provided. 4. Indicate the type of pump installed and complete the requested information. When installing pumps greater than 50 gpm, complete the additional information in this area. 5. Provide the information on other equipment which may be installed in the well. 6. Report test data as required by Rule 14.4. Spaces are provided to report all measurements made during the test. The report should show that the test complied with the provisions of the rules. If a test was not performed explain when it will be done. If available, report clock time when measurements were taken. 7. Record the type and the amount of disinfection used, how placed and the length of lima left in the hole. 8. Indicate if a water quality analysis was performed and submit a copy of the report if available. 9. Use the remarks area to note any additional information including additional equipment installed, water supply construction problems. 10. Fill in Company Name and Address of Contractor who installed pumping equipment. The report must be signed by the licensed contractor responsible for the installation of pumping equipment. 11. Submit completed report to: State of Colorado, Office of the State Engineer, 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203.