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PUMP INSTALLATION REPORT .:dam+-;- <br /> Pu�mp Make ' <br /> -. <br /> ^ <br /> r <br /> Powered by HP I:�-•• �•��Q-�� ■ <br /> A 1 : "x <br /> Pump Serial No. %> ?; <br /> r';, . WATER <br /> Motor Serial No. tY., ::{ ci w TABLE <br /> '�ti� 1- <br /> tJ <br /> Date Installea a <br /> -' <br /> Pump Intake Depth .i W <br /> Remarks 1 - -_ _ _ _ _ ___ _.. .t _� _ _ _ _ _ -_ - <br /> L._ .,' <br /> \ <br /> 4\ r� I <br /> •• llti } <br /> • 4. <br /> \, •, ti <br /> : . <br /> 41 •, <br /> § ;: <br /> S .t <br /> WELL TEST DATA WITH PERMANENT PUMP a. - s <br /> i . 4 <br /> 0 H <br /> Date Tested ` _ _ , E OF <br /> 11- 4 .t' DEPRESSION <br /> Static Water Level Prior to Test _ F a <br /> Length of Test Hours .f151111117.`. <br /> .,s tained yield (Metered} __ GPM <br /> Pumping Water Level <br /> Remarks � _ ,. <br /> T <br /> T <br /> CONTRACTORS STATEMENT <br /> The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or <br /> pump installation described hereon; that he has read the statement made hereon; knows the content <br /> thereof, and that the same 's true of his .wn knowledge. <br /> Signature -_ 4 / or.z.L License No. <br /> State of Colorado, n ty of I/ SS <br /> Subscribed and sworn to before me this_q day of Van 19 Kt . <br /> My Commission expires: _ _ 1-Z5 , 19 9Z,. <br /> ; Notary Public �� .,a <br /> � <br /> FORM TO RE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br /> WHITE AND GREEN copies must be filed with the State Engineer.PINK COPY is for the Owner and YELLOW COPY is for the Driller. <br />