Free Microsoft Word - Document1 - Colorado

FORM NO. GWS-32 08/2008

PUMP INSTALLATION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 818, Denver, CO 80203 Info (303) 866-3587 Main (303) 866-3581 Fax (303) 866-3589 http://www.water.state.co.us

For Office Use Only

1. WELL PERMIT NUMBER: 2. WELL OWNER INFORMATION NAME OF OWNER MAILING ADDRESS CITY TELEPHONE # ( ) 3. WELL LOCATION AS DRILLED: DISTANCES FROM SEC. LINES: SUBDIVISION: 1/4, 1/4 Sec. ft. from N or , Twp. N or S, Range ft. from , BLOCK E or E or W W section line. STATE ZIP CODE

S section line and , LOT

, FILING (UNIT) Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units Easting: Zone 12 or Zone 13 must be meters, Datum must be NAD83, Unit must be set to true N, Northing: STREET ADDRESS AT WELL LOCATION: 4. PUMP DATA: Type: Pump Model No. at RPM Feet, HP Drop/Column Pipe Size Volts Inches, Full Load Amps Kind of Drop Pipe Electric Shaft size Yes No, Depth ft. Engine Other inches Date Installed:

Pump Manufacturer: Design GPM: Pump Intake Depth:

ADDITIONAL INFORMATION FOR PUMPS GREATER THAN 50 GPM: Turbine Driver Type: Design Head 5. OTHER EQUIPMENT: Airline Installed Flow Meter Mfg. Meter Readout: 6. TEST DATA: Yes No, feet Orifice Depth ft. Number of Stages Monitor Tube Installed Meter Serial No. Gallons, Thousand Gallons, Acre feet Beginning Reading check box if Test Data is submitted on Supplemental Form. Date: Total Well Depth: Static Level: Date Measured: 7. DISINFECTION: Type 8. Water Quality analysis available: 9. Remarks: Yes ft. ft. Time: Rate (gpm): Pumping Level (ft): Amt. Used No If yes, please submit with this report.

10. I 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 filing 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 $5000 and/or revocation of the contracting license.] Company Name: Phone: License Number: ( ) Mailing Address: Signature: Print Name and Title Date

Rev 8/2008

INSTRUCTIONS FOR PUMP INSTALLATION AND TEST REPORT The report must be typed or printed in BLACK OR BLUE 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 name/number 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. Photocopy reproductions must retain margins and print quality of the original form. The original 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. ITEM INSTRUCTIONS: (numbers correspond with those on the front of this form) 1. 2. 3. Complete the Permit Number in full. Fill in Name and Mailing Address of Well Owner where correspondence should be sent. Complete the blocks for the actual location of the well. For wells located in subdivisions, the name, lot, block, filing, and street address must also be provided. An option to providing distances from section lines is to provide an accurate GPS location in UTM format. The required GPS unit settings must be as indicated on this form. Colorado contains two (2) UTM zones. Zone 13 covers most of Colorado. The boundary between Zone 12 th th and Zone 13 is the 108 Meridian (longitude). West of the 108 Meridian is UTM Zone 12 and east of the th th 108 Meridian is UTM Zone 13. The 108 Meridian is approximately 57 miles east of the Colorado-Utah state line. On most GPS units, the UTM zone is given as part of the Easting measurement, e.g. 12T0123456. Check the appropriate box for the zone. 4. 5. 6. Indicate the type of pump installed and complete the other requested information. When installing pumps greater than 50 gpm, complete additional information in this area. Provide the information on other equipment, which may be installed in the well. Report test data as required by Rule 12.4. 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 available, report clock time when measurements were taken. Record the type and the amount of disinfection used. Indicate if a water quality analysis was performed and submit a copy of the report if available. Use the remarks area to note any additional information including additional equipment installed, water supply construction problems, etc. 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.

7. 8. 9. 10.

Submit completed report to: State of Colorado, Office of the State Engineer, 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 IF YOU HAVE ANY QUESTIONS regarding any item on this form, please call the Division of Water Resources Ground Water Information Desk (303-866-3587), or the nearest Division of Water Resources Field Office located in Greeley (970-352-8712), Pueblo (719-542-3368), Alamosa (719-589-6683), Montrose (970-249-6622), Glenwood Springs (970-945-5665), Steamboat Springs (970-879-0272), or Durango (970-247-1845), or refer to our website at http://www.water.state.co.us for general information, additional forms, and access to state rules and statutes.