DWR_3799203

• Permitno: 177537
• Receipt Number: 0366827
• Document Type - Well Permit: Pump Installation
• Annotated?: No

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Form No, PUMP INSTALLATION AND PRODUCTION EQUIPMENT TEST REPORT For Office Use Only
GWS-32 State of Colorado, Office of the State Engineer
1313 Sherman St., Room 821, Denver, CO 80203 303,,866,3581
10/2016 www,wrater.state.co.us and dwrDermitson1ine@state,co.us
1. Well Permit Number: 177537 Receipt Number:
2. Owner's Well Designation:
3. Well Owner Name:Robert Et Dianna Hatch
4. Well Location Street Address:3479 Smith HiR Rd., Black Hawk CO 80422
5. GPS Well Location: OZone 12 EjZone 13 ETsting-463452 Northing:4407627 County:Gilpin
6. Legal Well Location: NE 1/4, SE 1/4, Sec. 3 Two, _3_ 0 N or S , , Range 72 E or W
Distances from Section Lines: 2300 ft. from JZ N or s 0 sec, tine, and 850 ft, from Z E or W 0 sec. tine
Subdivision- Lot Btock Filing (Unit)
7. Check Installation Type: DInitial Pump Installation IZIReplacement Pump [:]Change in Depth Oniy El Repair
8. Pump Data: Type: Submersible Date Instatted(mm/dd/yyyy):06/10/2021
Pump Manufacturer:Grundfos Pump Mode[ No. 7510-19PE
Design Gpm: 7 at Rpm 3450 HP'I 'Watts 230 Ful I Load Amps 9.1
Pump intake Depth-, 320 Feet, Drop/Column Pipe Size Inches, 1 Kind of Drop Pipe Sch8O PVC
Additional infcrrnatign_for_Eum s greater Than D GPM- Turbine Driver Type:ClEtectric [-]Engine [:]Other
DesignHead feet Number of Stages: Shaft size: inches
9. Other Equipment:
Airline Installed: Yes Ej No, Orifice Depth ft. Monitor Tube Installed: es No, Depth ft._
—
Flow Meter Mfg, — Meter Serial No,
Meter Readout:OGalions, C3Thousand Gallons, EjAcre feet Beginning Reading:
10. Cistern Information: Material: Capacity: gallons Date instatled:
11, Production Equipment Tort Datas shack box if data is submitted on Form Number GWS-39 Well Yield Test Report.
Date: 6,10/21
Total Melt Depth: 370 ft. Time: OU-120 — — — —
Static Level.: 40 ft, Rate (gpm): 9
Date Measured: 06/10/2021 Pumping Level (ft): 40
12. Disinfection: Type: HTH Amt, Usedu 100+pprn
13. Notification: Was Advanced Notification Required Prior to Installation?[:]Yes E]No, Date Notification Given:
14, Water Quality analysis available: 0Yes E3 No if yes, please submit with this report®
15. Remarks:
16. 1 have read the statements made herein and know the contents thereof. and they are true to my knowledge. This Co
document is signed (or name entered if filing online) and certified in accordance with Rute 17.4 of the Water Weil 7nstru]ction
Rules, 2 CCR 402-2. The filing of a document that contains false statements is a violation of section 37-91-108(l)(e), C�R,S,,
and is punishable by fines up to $1,000 and/or revocation of the contracting license, if filing online, the State Engineer
considers the entry of the licensed contractor's name to be compliance with Rule 17.4.
Company Name- Email- Phone w/area code- License Number:
GeoWater Services, LLC temple geovvaterusa.com [phone] 1504
1 —
Meiling Address: PO Box 2224 Evergreen, CO 80437
Sig narr01'&'1ipg onl' e) nt Name and Title Date:
Mike Temple (Owner) /VX1