2011-02-18_PERMIT FILE - M2005065

• Permit No: M2005065
• IBM Index Class Name: PERMIT FILE
• Doc Date: 2/18/2011
• Doc Name: Response to SEO comments
• From: Charles R Ponchak
• To: DRMS
• Email Name: DMC
• Media Type: D
• Archive: No

FORM NO PUMP INSTALLATION AND TEST REPORT
.
Gv S-32
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER For Olfim Use Only
o82m 1313 Sherman St., Room 818, Denver, CO 80203
Info [phone] Main [phone]
Fax [phone] hIIp:1Avww.water.state.co us
1. WELL PERMIT NUMBER: 63417 F
2. WELL OWNER INFORMATION
NAME OF OWNER
MAILING ADDRESS
P.O. .767
CITY
Silverton
STATE Colorado
2181433
TELEPHONE #
3. WELL LOCATION AS DRILLED: -MW 114, _S"14 Sec.,i 1 Twp. 4 9 N or 0 S, Range _F ? E or k] W
DISTANCES FROM SEC. LINES: 8 4 1 R from ? N or [}S sermon fine and 6 3 0 ' fL from ? E or EJW section line.
SUBDIVISION: LOT. BLOCK . FILING (UNIT)
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Egg= 2 71.16 1
must be meters, Datum must be NADs3, Unit must be set to tflle N
[] Zone 12 or [I Zone 13
,
Northing: 419 2 6 5 0
STREET ADDRESS AT WELL LOCATION:
4. PUMP DATA Type: S i ihm 0 r c i h l A Date Insbikxt - eT u n e 19
2 0 0 65
,
Pump Manufacturer. G r u n f o s Pump Model No. 25515-9
Design GPM: i 5_ at RPM 2$ 8 0 HP -- i.5 ----- volts 230 Full Load Amps 5
Pump Intake Depth: 4-- Feet, Drop/Column Pipe Size 1 . 5 Indies, Kind of Drop Pipe b 1 a c k no 7 y
ADDITIONAL INFORMATION FOR PUMPS GREATER THAN 50 GPM: Turbine Driver Type. ? Electric E] Engine [] Other
Design Head feet Number of Stages Shaft size inches
S. OTHER EQUIPMENT:
Airline Installed [] Yes [2 No. OrificeDepth fL Monitor Tube Installed (] Yes E2 No, Depth ft
Flow Meter Mfg. Meter Serial No
Meter Readout [] Gallons, ? Thousand Gallons, [] Acre feet Reading
Beginning
>. TEST DATA. (] check box if Test Data is submitted on Supplemental Form.
Date: 6-17
Total Well Depth: 6 ft. Tom: noon
Static Level: 6 ft. Rate (gprn): 15
-
Date Measured: 6-1 6-nfi Pumping Level ?
'. DISINFECTION: Type AmL Used
1. Water Quality analyYsiss available: [] Yes No If yes, please submit with this reporL
1. Remarks:-- pit water level never anged during 8 hour pump test

0. 1 have read the statements made herein and know the contents thereof and they are true to my knowledge. This document is signed and
certified in accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402-2. [The fang of a document that contains false
statements is a violation of section 37-91-108(1)(e), C.R.S., and is punishable by fines up to 35000 andlor revocation of the contracting
license.
:ompany Name: Phone: License Number

9 -387-
lailing Address: 5243.
- P.O.BoX '71,

C11 21433
ignature: - :' a
rid) Tide
ate

Jack Clark, JR. Owner 2-16-2011
_. f
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