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PUMP INSTALLATION REPORT <br />Pump Make L <br />Type �.t.t JL. "/td <br />Powered by _ :,13.._ HP 7 Y <br />Pump Serial No... `i 45.1 Q i 1 <br />Motor Serial No. 27 13 J 2 6 <br />Date Installed & p7, -/-P L- I <br />Pump Intake Depth ` 9_ 1P1 <br />Remarks 1111 <br />WELL TEST DATA WITH PERMANENT PUMP <br />Date Tested 04 I '4 <br />Static Water Level Prior to Test I `�- <br />Length of Test Hours <br />Sustained yield (Metered) �C C GPM <br />Pumping Water Level <br />Remarks <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 is true of his own knowledge, <br />Signature, t�A4- License No. <br />State of Colorado, County of SS <br />Subscribed and pworn tofiefore me this day ofG , 19 <br />My Commiss(o : xpires: <br />Notary Pub; <br />• <br />FORM TO RE MADE OUT IN QUADRUPLICATE; WHITE FORM must be en original copy on both sides end signid. <br />WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner end YELLOW COPY is for the Driller. <br />