HomeMy WebLinkAbout5.3 Suma Pump Installation and Test Report 2015.03.02FORM NO.
GWS -32
04/2012
PUMP INSTALLATION AND TEST REPORT
STATE OF COLORADO, OFFICE OF THE STATE ENGINEER
1313 Sherman St., Room 821, Denver, CO 80203
Main (303) 866-3581 Fax (303) 866-3589,
dwrpermitsonline(c�state.co.us
1. WELL PERMIT NUMBER: 77964-F
2. WELL OWNER INFORMATION
NAME OF OWNER
Jamie Knight Suma Separate Property Trust
MAILING ADDRESS
360 Riverside Drive
CITY
Basalt
TELEPHONE # (area code)
970-989-3579
STATE
Co
ZIP CODE
81621
For Office Use Only
3. WELL LOCATION AS DRILLED: NW 1/4, SW 1/4 Sec. 31 , Twp. 7 r N or iXS, Range 87 l E or 11W
DISTANCES FROM SEC. LINES: 3260 ft. from ix N ori S section line and 1310 ft. from [' E or FX`W section line.
SUBDIVISION: St. Finnbar Farm Subdivision LOT 9 BLOCK ,
Optional GPS Location: GPS Unit must use the following settings: Format must be UTM, Units
must be meters, Datum must be NAD83, Unit must be set to true N, [ Zone 12 or €__ Zone 13
STREET ADDRESS AT WELL LOCATION:
FILING (UNIT)
Easting:
Northing:
4. PUMP DATA: Type: Submersible
Pump Manufacturer: Grundfos
Design GPM: 15 at RPM 10000
HP 3/4
Pump Model No.
Date Installed(mm/dd/yyyy): 07/23/2014
15SQE07-180
Volts 230 Full Load Amps 7.3
Pump Intake Depth: 40 Feet, Drop/Column Pipe Size Inches 1 1/` Kind of Drop Pipe Sch 80 PVC
ADDITIONAL INFORMATION FOR PUMPS GREATER THAN 50 GPM: Turbine Driver Type0 Electric DEngine DOther
Desi.n Head feet Number of Sta.es Shaft size inches
5. OTHER EQUIPMENT:
Airline Installed Yes No, Orifice Depth ft. Monitor Tube Installed Yes No, Depth ft.
Flow Meter Mfg. Master Meter Meter Serial No.
Meter Readout:lGallons, D housand Gallons, OAcre feet Beginning Reading
6. TEST DATA: check box if Test Data is submitted on Supplemental Form.
Total Well Depth: 45
Static Level: 6-3 1/2" ft
Date Measured: 07/23/2014
Date:
ft. Time:
Rate (gpm):
Pum
in
Level ft
07/23/2014
15
7'-11"
0
7. DISINFECTION: Type Chlorox
Amt. Used 1/2 Gallon
8. Water Quality anal sis available$ Yes No If es, please submit with this report.
9. Remarks:
10. I have read the statements made herein and know the contents thereof, and they are true to my knowledge. By signing or entering my name I
am certifying 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 w/area code: License Number:
Samuelson Pump Company, Inc. 970-945-6309 1050
Mailing Address:
P.O. Box 297, Glenwood Springs, CO 8160
Sign or Enter Name and Title
Raun E. Samuelson, President
,„tficyze 20,5
Date (mm/dd/yyyy)