Attach-03-Well_Permit.pdf

FORK NO

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PUMP INSTALLATION AND TEST REPORT

STATE OF COLORADO OFFICE OF THE STATE ENGINEER

For Ofte Um Doty

RECEIVEDRECEIVED

OU 19 94

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1 WELL PERMrr NUMBER 178043

2 OWNER NAME S U S Forest Service Mailing Address P O Box 28127 City St Zip Lakewood Colorado 80228

Phone 303 275 5108

3 WELL LOCATION AS DRILLED 1 4 NW 1 4 Sec 2 Twp 12 Range q8 W

DISTANCES FROM SEC LINES

2700 ft from Sec line and 2yp ft from Sec line qp Y 1 Or MYtt

SUBDIVISION LOT BLOCK FILING UNIT

STREET ADDRESS AT WELL LOCATION

4 PUMP DATA Type Submersible Installation Completed 9 26 94

Pump Manufacturer Goulds Pump Model No 7GS05421

Design GPM 7 at RPM 3450 HP 1 2 Volts 1 18 Full Load Amps 12 Pump Intake Depth 136 Feet Drop Column Pipe Size 1 Inches Kind Schedule 80 P V C

ADDITIONAL INFORMATION FOR PUMPS GREATER THAT 50 GPM

TURBINE DRIVER TYPE Electric Engine Other

Design Head feet Number of Stages Shaft size inches

5 OTHER EQUIPMENT

Airline Installed Yes No Orifice Depth ft Monitor Tube Installed Yes No Depth ft

Flow Meter Mfg Meter Serial No

Meter Readout Gallons Thousand Gallons Acre feet Beginning Reading

6 TEST DATA Check box if Test data is submitted on Supplemental Form Date 9 26 94

Total Well Depth 150 Time 1 Hour

Static Level 1 14 Rate GPM 12 Date Measured Pumping Lvl 115

7 DISINFECTION Type HTH 65 Amt Used 5oz Hand 24 Hour

8 Water Quality analysis available Yes No s Remarks Water cleared immediately very little draw down recovered quickly PxcPllent wPll

0 1 have read the statements made herein and know the contents thereof and that they are true to my knowledge Pursuant to Section 24 4 104 13 a C R S the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor

CONTRACTOR Mark Reeves Phone 7 19 746 2032 Lid No 1092 Mailing Address Box 175 Gardner Colorado 811040

Namejritle Please type or print Signal a Date

Mark Reeves Owner 10 1 9

INSTRUCTIONS FOR PUMP INSTALLATION REPORT

The report must be typed or printed in BLACK 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 gfound surface

This form may be reproduced by photocopy methods or by computer generation with prior approval by the State Engineer

The original and one copy of this forth 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

If this forth is submitted in conjunction with the Well Completion and Test Report forth number GWS31 ONLY THE PERMIT NUMBER AND OWNER NAME NEED TO BE COMPLETED in items 1 and 2

1 Complete the Permit Number in full

2 Fill in Name and Mai Address of Well Owner where correspondence should be sent

3 Complete the blocks for the actual location of the well For wells located in subdivisions the lot block and subdivision information must also be provided

4 Indicate the type of pump installed and complete the requested information When installing pumps greater than 50 gpm complete the additional information in this area

5 Provide the information on other equipment which may be installed in the well

6 Report test data as required by Rule 13 9 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 a test was not performed explain when it will be done If available report clock time when measurements were taken

7 Record the type and the amount of disinfection used how placed and the length of time left in the hole

6 Indicate if a water quality analysis was performed and submit a copy of the report if available

9 Use the remarks area to note any additional information including additional equipment installed water supply construction problems

10 Fill in Company Name and Address of Contractor who constructed the well The report must be signed by the licensed contractor responsible for the installation of pumping equipment

1weNM0 e011

WELL CONSTRUCTION AND TEST REPORT

STATE OF COLORADO OFFICE OF THE STATE ENGINEER

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1 YR

SEP 2 9 94

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1 WELL PERMIT NUMBER 178043

Z OWNER NAME S U S Forest Service

Mailing Address P 0 Any 25127 City SL Zip lakawond Colorado 80225 Phone 303 275 5108

3 WELL LOCATION AS DRILLED 1 1 4 NI 1 4 Sec 2 Twp 12 5 Range 95 W

DISTANCES FROM SEC LINES

2700 ft from North Sec line and 250 ft from West Sec line OR

SUBDIVISION LOT BLOCK FILING UNIT

STREET ADDRESS AT WELL LOCATION

4 GROUND SURFACE ELEVATION 10 000 ft DRILLING METHOD Air Rotary

DATE COMPLETED 9 14 94 TOTAL DEPTH 150 ft DEPTH COMPLETED 145 ft

S GEOLOGIC LOG

Depth Description of Material type Sae Color Water Location

6 HOLE DIAM in From ft To ft

11 0 20 5 6 1 n 5 150

Or to re basalt re clay seams

7 PLAIN CASING

OD in Kind Wall Size From ft To ft

8 5 8 Steel 250 1 20 5 5 P V C 250 6 105

PERK CASING Screen Slot Size 030 5 P V C 250 ins

10 to 1 Red c a some basalt 15 to 201 Brown clay some basalt basalt20 to 251 Grey brown clay seaR

75 to 35 Grey t

401 tn 651 Grey hasalt

80 to 85 Grev basalt

5 to 95 R ed sandstone some clay some basalt

95 to 1001 Brown sandstone clay1001 to IIS Ragalt brown some

8 FILTER PACK

Material PPa Gravel

Sae 3 8 Interval 15 to 145

9 PACKER PLACEMENT

Type

Depth

Stone

115 to 150 re asa some an c ay some felspar

10 GROUTING RECORD

Material Amount Density Interval Placement Cement 40 Gal 7 to 1 0 20 5 P DREMARKS Hit Water 115

I11 DISINFECTION Type HTH 65 Amt Used 50Z

12 WELL TEST DATA Check box if Test Data is submitted on Form No GWS 39 Supplemental Well Test TESTING METHOD Submersible Pump Static Level 113 ft Date Time measured 9 14 94 1 2 07 P Production Rate 14 gpm

Pumping level 116 ft DateMme measured 9 14 94 3 07 P Test length hrs I

Remarks little drawdown recovered uickl

13 1 have read the statements made herein and know the contents thereof and that they are We to my knowledge Pursuant to Section 21 4104 13 C R S the making of false statements herein constitutes perjury in the second degree and is punishable as a class 1 misdemeanor

CONTRACTOR B F Kis s ner Drilling Company Phone 303 856 3177 Lic No 817 Mailing Address L 258U 73oidareage Co ore 0 814T3

Name T rtle Please type or print

Bill F Kissner Owner

Signature Date

9 27 94

M

INSTRUCTIONS FOR WELL CONSTRUCTION AND TEST REPORT

The report must be typed or printed in BLACK IN 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 font may be reproduced by photocopy methods or by computer generation with prior approval by the State Engineer

The original and one copy of this for must be submitted to the State Engineers Office within 60 days after completing the well or 7 days after the permit expiration date whichever is earlier Another copy of the font must be provided to the well owner

1 Complete the Well Permit Number in full

2 Fill in Name and Mailing Address of Well Owner where correspondence should be sent

3 Complete the blocks for the actual location of the well where drilled If the owner has more than one well serving this property provide the identification Owners Designation for this well DO NOT USE THE OWNER SUPPUED LOCATION unless a survey has been provided For wells located in subdivisions the lot block and subdivision information must also be provided

4 Report the ground surface elevation in feet above sea level if available This value may be obtained from a topographic map Describe the drilling method used to construct the well and the date completed Indicate the total depth drilled and the actual completed depth of the well

5 Fully describe the materials encountered in drilling Do not use formation names unless they are in conjunction with a description of materials

Examples of descriptive terms include Grain size Boulders gravel sand sift clay Hardness Loose soft tight hard very hard Color All materials Most critical in sedimentary rock Depth when water is encountered if it can be determined

6 Provide the diameters of the drilled bore hole

7 The outside diameter kind wall thickness and interval of casing lengths must be indicated

8 Indicate the type and size of filter gravel pack and the interval where placed

9 Indicate the type and setting depth for any packers installed

10 The density of the grout slurry must be re rted andmay be indicated as pounds per gallon gallons of water per sack total gallons of water and number of sacks used etc Specify the grout placement method i e tremie pipe or positive displacement The percentage of additives mired with the grout should be reported under remarks

11 Record the type and the amount of disinfection used how placed and the length of time left in the hole

12 Report well test data as required by Rule 10 7 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 a test was not performed explain when it will be done If available report clock time when measurements were taken

13 Fill in Company Name and Address of Contractor who constructed the well The report must be signed by the licensed contractor responsible for the construction of the well

Farm No

GINS 26

APPLICANT

OFFICE OF THE STATE ENGINEER

COLORADO DIVISION OF WATER RESOURCES

818 Centennial Bldg 1313 Sherman St Denver Colorado 80203 303 8863581

US FOREST SERVICE

G TOLLEFSON

P O BOX 25127

LAKEWOOD CO 80225

303 275 5108

PERMIT TO CONSTRUCT A WELL

LIC

WELL PERMIT NUMBER IL78043

DIV 4 CNTY 15 WD 40 DES BASIN MD

Lot Block Filing Subdiv

APPROVED WELL LOCATION

DELTA COUNTY

SW 1 4 NW 1 4 Section 2

Twp 12 S RANGE 95 W 6th P M

DISTANCES FROM SECTION LINES

2700 Ft from North Section Line

250 Ft from West Section Line

ISSUANCE OF THIS PERMIT DOES NOT CONFER A WATER RIGHT

CONDITIONS OF APPROVAL

1 This well shall be used in such a way as to cause no material injury to existing water rights The issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action

2 The construction of this well shall be in compliance with the Water Well Construction and Pump Installation Rules 2 CCR 402 2 unless approval of a variance has been granted by the State Board of Examiners of Water Well Construction and Pump Installation Contractors in accordance with Rule 17

3 Approved pursuant to CRS 37 92 602 3 b 1 and the policy of the State Engineer for appropriation of ground water tributary to the Ward Creek Tongue Creek North Fork of the Gunnison River system

4 The use of ground water from this well is limited to drinking and sanitary facilities as described in CRS 37 92 602 1 c for a Forest Service visitor center Water from this well shall not be used for lawn or landscape irrigation or for any other purpose outside the visitor center building structure 5 The maximum pumping rate shall not exceed 15 GPM

6 The maximum annual amount of groundwater to be diverted by this well shall not exceed 113 acre foot 108 600 gallons

7 Approved as the only well on a site of 40 acres described as the SW 1 4 of the NW 1 4 of Sec 2 T12S R95W 6th P M Delta County

8 The return flow from the use of the well must be through an individual waste water disposal system of the non evaporative type where the water is returned to the same stream system in which the well is located

9 A totalizing flow meter must be installed on this well and maintained in good working order Permanent records of all diversions must be maintained by the well owner recorded at least annually and submitted to the Division Engineer upon request

10 This well shall be constructed not more than 200 feet from the location specified on this permit

APPROVED 1 D w r n

J

FM44 fGd v v t

5 1814 7 BY

Receipt No

0022667AE

1n r

DATE ISSUED MAY 19 199 EXPIRATION DATE MAY 19 199E

WIZJ 5 P e 76 COLORADO DIVISION OF WATER RESOURCES

818 Centennial Bldg 1313 Sherman St Denver Colorado 80203

PERMIT APPLICATION FORM

it

Application must be complete where applicable Type or print in BLACK INK No overstrikes or erasures unless initialed

A PERMIT TO USE GROUNDWATER

rx I A PERMIT TO CONSTRUCT A WELL

FOR I A PERMIT TO INSTALL A PUMP

REPLACEMENT FOR NO

OTHER

WATER COURT CASE NO

1 APPLICANT mailing address

UNITED STATES OF AMERICA

NAME USDA Forest Service By G Tollefson

STREET r O Box 25127

CITY

Lakewood Colorado 80225

TELEPHONE NO 303 275 5108

2 LOCATION OF PROPOSED WELL

Grand Mesa N 7ana junction Ranger District

County Delta

SW Y of the NW Y Section 2

Twp 12 S Rng 95 W Sixth

W 51 IE WI

3 WATER USE AND WELL DATA

Proposed maximum pumping rate gpm

Average annual amount of ground water 1 3 to be appropriated acre feet

Number of acres to be irrigated

Proposed total depth feet

Aquifer ground water is to be obtained from

Glacial Deposits

Owner s well designation Grand Mesa Visitor Center

GROUND WATER TO BE USED FOR

HOUSEHOLD USE ONLY

I DOMESTIC 1

I LIVESTOCK 2

ptx COMMERCIAL 4

OTHER 9

no irrigation 0

1 INDUSTRIAL 5

1 IRRIGATION 6

I MUNICIPAL 8

DETAIL THE USE ON BACK IN 11

4 DRILLER

Name Licensed Contract to be let Street

City

Telephone No Lic No

RECEIVLO

APR 13 94

WATERSTATE

COLO

FOR OFFICE USE ONLY DO NOT WRITE IN THIS COLUMN

Receipt No j 1 22967 Basin Dist

JCONDITIONS OF APPROVAL

i

This well shall be used in such a way as to cause no material injury to existing water rights The issuance of the permit does not assure the applicant that no injury will occur to another vested water right or preclude another owner of a vested water right from seeking relief in a civil court action

I Or rd CK Ton54tCK N Fk c mnlsrrl

APPLICATION APPROVED

PERMIT NUMBER

DATE ISSUED

EXPIRATION DATE

BY

KPI

STATE ENGINEER

COUNTY S 0 V

I 1

5 THE LOCATION OF THE PROPOSED WELL and the area on which the water will be used must be indicated on the diagram below Use the CENTER SECTION 1 section 640 acres for the well location

4 I f I

1 MILE 5280 FEET j

Section is an oversized sectiop in the I North So tth Direction I

NORTH SECTION LINE

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NORTH1

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T

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The scale of the diagram is 2 inches 1 mile Each small square represents 40 acres

WATER EQUIVALENTS TABLE Rounded Figuresl

An acre foot covers 1 acre of land 1 foot deep 1 cubic foot per second cfs 449 gallons per minute 4gpm1

A family of 5 will require approximately 1 acre foot of water per year 1 acre foot 43 560 cubic feet 325 900 gallons

1 000 gpm pumped continuously for one day produces 4 42 acre feet

6 THE WELL MUST BE LOCATED BELOW

by distances from section lines

2700 ft from North sec line north or56uth

250 West ft from sec line eas or west

LOT BLOCK FILING w

SUBDIVISION

7 TRACT ON WHICH WELL WILL BE

LOCATED Owner USA USDA Forest Service No of acres 40 Will this be the only well on this tract

8 PROPOSED CASING PROGRAM

Plain Casing

6 in from 0 ft to 20 ft

4 1 2 in from 6 ft to ft

Perforated casing

4 1 2 in from 90 ft to 100 ft in from ft to

9 FOR REPLACEMENT WELLS givedistance and direction from old well and plans for plugging it

10 LAND ON WHICH GROUND WATER WILL BE USED

Owner s United States of America USDA Forest Service No of acres

Legal description SW 1 4 NW 1 4 Section 2 T 12S R 95W Sixth PM

01 DETAILED DESCRIPTION of the use of ground water Household use and domestic wells must indicate type of disposal system to be used The water system will service a Forest Service visitor center see estimate ri arly use on Sago 3 Disposal of waste water will be via a septic tank leach fie 16 system

12 OTHER WATER RIGHTS used on this land including wells Give Registration and Water Court Case Numbers Type or right Used for purpose Description of land on which used

HE

OF

STATE S THAT THE INFORMATION SET FORTH HEREON IS

OF HIS KNOWLEDGE

li

Use additional sheets of paper if more space is required

SOUTH SECTION LINE I

The scale of the diagram is 2 inches 1 mile Each small square represents 40 acres

WATER EQUIVALENTS TABLE Rounded Figuresl

An acre foot covers 1 acre of land 1 foot deep 1 cubic foot per second cfs 449 gallons per minute 4gpm1

A family of 5 will require approximately 1 acre foot of water per year 1 acre foot 43 560 cubic feet 325 900 gallons

1 000 gpm pumped continuously for one day produces 4 42 acre feet

6 THE WELL MUST BE LOCATED BELOW

by distances from section lines

2700 ft from North sec line north or56uth

250 West ft from sec line eas or west

LOT BLOCK FILING w

SUBDIVISION

7 TRACT ON WHICH WELL WILL BE

LOCATED Owner USA USDA Forest Service No of acres 40 Will this be the only well on this tract

8 PROPOSED CASING PROGRAM

Plain Casing

6 in from 0 ft to 20 ft

4 1 2 in from 6 ft to ft

Perforated casing

4 1 2 in from 90 ft to 100 ft in from ft to

9 FOR REPLACEMENT WELLS givedistance and direction from old well and plans for plugging it

10 LAND ON WHICH GROUND WATER WILL BE USED

Owner s United States of America USDA Forest Service No of acres

Legal description SW 1 4 NW 1 4 Section 2 T 12S R 95W Sixth PM

01 DETAILED DESCRIPTION of the use of ground water Household use and domestic wells must indicate type of disposal system to be used The water system will service a Forest Service visitor center see estimate ri arly use on Sago 3 Disposal of waste water will be via a septic tank leach fie 16 system

12 OTHER WATER RIGHTS used on this land including wells Give Registration and Water Court Case Numbers Type or right Used for purpose Description of land on which used

HE

OF

STATE S THAT THE INFORMATION SET FORTH HEREON IS

OF HIS KNOWLEDGE

li

Use additional sheets of paper if more space is required