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FORM M0. <br />NS•32 <br />11/90 <br />~/ PUMP INSTALLATION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />~.~ WELL PERMfT NUMBER 161244 <br />OWNER NAME(S) Julia Silva <br />Mailing Address 1'i800 Co. Rd. 21.4 <br />City, SL Zp Meaton~ Colorado Al(1Q1_ <br />Phone (~10 ) AF,A_i~Ali <br />WELL LOCATION AS DRILLED: NH 1/4 NE 1/4, Sec.~~Twp. 3~ S , Range~_ Y <br />DISTANCES FROM SEC. LINES: <br />~~ R from N Sea Gne. and 1990 ft from E Sec. line. <br />roan a .o~m, wt a wrq <br />SUBDMSION: LOT_BLOCK FILING(UNIT) <br />STREET ADDRESS AT WELL LOCATION: <br />PUMP DATA:Tyoe Subaeraible <br />Pump Manufacturer Air Motor <br />Design GPM Unknoxn at RPM <br />Pump Imake Depth 7D Feet, <br />TURBINE DRNER TYPE: LJ Electric LJ Engine <br />Design Head feet Number of Staa~ <br />Irts'=~l?ticn Corrple!ed <br />Pumo Model No. <br />Other <br />Shaft size inches. <br />F« oniw u.e onp <br />+r,\ <br />~uN 17's2 <br />sua; ~' ~ . <br />OTHER EQUIPMENT: <br />Airline Installed ^ Yes ®No, Orifice Depth fL .Monitor Tube Installed ^ Yes ©No, Depth fL <br />Flow Meter Mfg. Meter Serial No. <br />Meter Readout ^ Gallons, ^ Thousand Gallons, ^ Aae feet, ^ Beginning Reading <br />TEST DATA: ^ Check box 'rf Test data is submitted <br />Date <br />Total Welt Depth 80' Time <br />Static Level ~$' ~ Rate (GPM) _ <br />Date Measured 44 t/ o/q2 Pumoina Lvl. <br />7.~ DISINFECTION: Type <br />Water <br />Remarks <br />HTH <br />available. ^ Yes ®No <br />Form. <br />Used 4 tab2eepooaa <br />0. I have read the statements made herein and know the convents thereof, and that they are true to my knc <br />(Pursuant to Section 244104 (13)(a) C.R.S., the making of false statemems herein constitutes perjury in the <br />degree and is punishable as a class 1 misdemeanor.] <br />CONTRACTOR Sa <br />Mailing Address-~ <br />M, Sayder -Owner <br />(Please type or print) Signature <br />.,_ . <br />Pipe <br />Phone 7( 19) 846-2145 Lic. No.~. <br />Date <br />