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i <br />KIM NO- ? PtiUMP INSTAIIATION AND TEST REPORT For Office Use only <br />GWS-32 <br />10184 <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1. WELL PERMIT NUMBER <br />2- OWNER NAME(S) y1 Cdrokwe I(--?eWs RECEIVEE <br /> Mailing Address _ IO O S i,.) A_,A!ye # <br /> City, St. Zip 1 Q 1 e W 0n <br />'11 - <br />C' n y...,...?3..5 L 1& <br /> <br />DEC 1$ 1991 <br /> Phone ( ) <br /> <br />3 WAFT k Efj?lJGr E <br />WELL LOCATION AS DRILLED: 1/4W 114, Sec. Twp. Range WsrArFlI f , <br /> DISTANCES FROM SEC. LINES: t <br /> <br />Sec. line. <br />2(? ft. from <br />on Sec, line. and ft. from W_(e or we!M <br /> a or i <br />SUBDIVISION: LOT BLOCK FILING(UNIT) <br /> STREET ADDRESS AT WELL CATION: J 2-110 gag <br />4- PUMP DATA: Type SuIIom eVSi O f2 u1.1&t2 Installation Completed <br /> Pump Manufacturer Pump Model No. 93h ?) L, <br />Design GPM at RPM 340 , HP , Volts .2-3QFull Load Amps <br /> Pump Intake Depth 2,15 Feet, Drop/Column Pipe Size a Inches, Kind fob Q? i & <br /> ADDITIONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM: <br /> TURBINE DRIVER TYPE: 0 Electric 0 Engine 0 Other <br /> Design Head feet, Number of Stages Shaft size inches. <br /> <br />5. OTHER EQUIPMENT: <br />Airline Installed 0 Yes ? No, Orifice Depth ft. Monitor Tube Installed 0 Yes 0 No, Depth ft. <br /> Flow Meter Mfg. Meter Serial No. <br /> Meter Readout 0 Gallons, 0 Thousand Gallons, 0 Acre feet, 0 Beginning Reading <br />6. TEST DATA: ? Check box if Test data is submitted on Supplemental Form. <br /> Date <br />Total Well Depth 3 i Time <br /> Static Level Rate (GPM) 2-S <br /> Date Measured Q l Pumping LA. 3l5' <br /> <br />7. y / <br />DISINFECTION: Type " T t+ Amt. Used t 1/ 2 C-U-p C <br />8. Water Quality analysis available. 0 Yes 0 No <br />9. Remarks <br /> <br /> <br /> <br /> <br /> <br /> <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 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in the second <br />degree and is punishable as a class 1 misdemeanor.] <br />CONTRACTOR , LA Ok Ph a 03-, L.ic. No. <br />Mailing Address Go t2 L-? <br />Name/Title (Please type or print) Signatur?e_ Date <br />