Free Microsoft Word - Document5 - Colorado

Form No. GX-01 1/2006

GEOEXCHANGE LOOP FIELD CONSTRUCTION AND TEST REPORT
STATE OF COLORADO OFFICE OF THE STATE ENGINEER 1313 Sherman St. Rm. 818 Denver CO 80203 Phone - info: (303) 866-3587 Main: (303) 866-3581 Fax: (303) 866-2223 http://www.water.state.co.us -GX

For Office Use Only

1. PERMIT NUMBER: 2. OWNER NAME(S): MAILING ADDRESS:

CITY: PHONE: ( ) County:

STATE

ZIP Div WD Basin MD

3. PROPERTY LOCATION:

Parcel ID Number (Optional): (City ) N. or S., Range E. or , LOT N. or W., , BLOCK S. Line, Ft. Easting Northing (State) (Zip) P.M. , FILING/UNIT E. or W. Line.

(STREET ADDRESS AT LOOP FIELD LOCATION) 1/4 of the 1/4, Sec. , Township

SUBDIVISION NAME: 4. LOOP FIELD POINT OF ORIGIN: DISTANCE FROM SECTION LINES:

Ft.

Optional: GPS well location information in UTM format. The following GPS settings are required: Format must be UTM. Units must be in meters. Datum must be NAD83. Unit must be set to true north. Zone 12 or Zone 13 Was GPS unit checked for above items? YES NO 5. LOOP MATERIAL: 7. CIRCULATING FLUID (include mixture percent): 8. FIELD TYPE: POND LOOPS VERTICAL DIRECTIONAL HORIZONTAL (Trench) 10. TRENCH INFORMATION: Average Depth: ft. Average Width: ft. Excavated with 11. BACKFILL MATERIALS: DIAMETER:

6. DATE COMPLETED: ft. in.

9. DEPTH OF LOOPS: 12. HOLE DIAMETER: NUMBER OF HOLES: 13. GROUT:

Type and amount of each material (INCLUDE WATER):

14. TEST DATA: Prior to installation: Design/Test Pressure (psi): Test Length (hrs): Date/Time Measured: 15. NAME OF CERTIFIED INDIVIDUAL (type or print): Mailing Address:

After Installation: Test Pressure (psi): Test Length (hrs): Date/Time Measured:

Certification No. GT-

Phone Number: YES NO

The Division of Water Resources' Online Mapping tool was used to identify rights located within ½ mile.

I 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.]
Signature: Date:

Form No. GX-01 (1/2006)

COLORADO DIVISION OF WATER RESOURCES DEPARTMENT OF NATURAL RESOURCES INSTRUCTIONS FOR GEOEXCHANGE LOOP FIELD CONSTRUCTION AND TEST REPORT FORM
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. Incomplete forms will be returned for completion. This form may be reproduced by photocopy methods, or by computer.

GENERAL INSTRUCTIONS: (numbers correspond with those on the front of this form)
1. 2. 3. Print the loop field(s) number in the space provided at the top of the form. Print the Owner's Name and indicate the mailing address and phone number. Complete the well location information of where the loop field(s) was drilled. Complete the parcel I.D. number if known. The loop field(s) location must include the ¼, ¼, Section, Township, Range, Principal Meridian, and distances from section lines. If the loop field(s) is located in subdivisions the lot, block, and subdivision information must also be provided. Complete the loop field(s) point of origin by providing the distances from section lines. An option to providing distances from section lines is to provide an accurate GPS location in GPS 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 and Zone 13 is the 108th Meridian (longitude). West of the 108th Meridian is UTM Zone 12 and east of the 108th Meridian is UTM Zone 13. The 108th 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. Complete the type of material that the loop field(s) is made from. Also include the diameter of the tubing. Enter the date that the loop field(s) was completed. Enter the type of circulating fluid that is in the loops. Include the percentages of mixtures. Indicate the type of loops that were installed Indicate the depth that the loops were installed at.

4.

5. 6. 7. 8. 9.

10. Enter the average depth and width of the trenches that were dug when the loop field(s)s were installed. Indicate the equipment that was used to excavate the trenches. 11. List the materials used to backfill the trenches. 12. Enter the hole diameter and the number of holes. 13. Enter the type and amount of grout used. You must include the amount of water used in the mix. 14. Enter the test pressure, length of test, and date/time of the test of the loop field(s) prior to installation. Enter the test pressure, length of test, and date/time of the test of the loop field(s) after it was installed. 15. Enter the name, mailing address, and phone number of the person who is certified to install this loop field(s). Enter the individual's certification number. Indicate if the Division of Water Resources' Online Mapping Tool was used to identify water rights within ½ mile of the loop field(s). The report must be signed by the certified individual responsible for the construction of the loop field(s). Submit completed report to: State of Colorado, Office of the State Engineer, 818 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 If you have questions, contact the Denver or the Division Office where your loop field(s) are located. Division 1 810 9th St., Ste. 200 Greeley, CO 80631 (970) 352-8712 Fax (970) 392-1816 Division 5 Direct mail to Box 396 Glenwood Spgs CO 81602 50633 U.S. Hwy 6 & 24 Glenwood Spgs., CO 81601 (970) 945-5665 Fax (970) 945-8741 Division 2 310 E. Abriendo Ave., Ste. B Pueblo, CO 81004 (719) 542-3368 Fax (719) 544-0800 Division 6 Direct mail to Box 773450 505 Anglers Dr. Suite 101 Steamboat Spgs, CO 80477 (970) 879-0272 Fax (970) 879-1070 Division 3 301 Murphy Drive Alamosa, CO 81101 (719) 589-6683 Fax (719) 589-6685 Division 7 701 Camino Del Rio, Ste. 205 Durango, CO 81301 (970) 247-1845 Fax (970) 259-0944 Division 4 1871 East Main St. Montrose, CO 81401 (970) 249-6622 Fax (970) 249-8728 Denver Office 1313 Sherman St., Rm. 818 Denver, CO 80203 (303) 866-3587 Fax (303) 866-2223