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PUMP INSTALLATION REPORT <br /> Pump Make ' <br /> Type <br /> Powered by HP <br /> Pump Serial No, <br /> tt <br /> WATER <br /> Motor Serial No. w W TABLE <br /> > > <br /> h <br /> Date Installedcc <br /> N <br /> .� W <br /> Pump intake Depth <br /> Remarks <br /> C <br /> W <br /> WELL TEST DATA WITH PERMANENT PUMP 4 <br /> 0 •�. <br /> Date Tested CONE OF <br /> ti a- ;.`' DEPRESS10h <br /> Static Water Level Prior to Test o <br /> Length of Test Hours <br /> "ems <br /> Sustained yield (Metered)---.,----_.. GPM <br /> Pumping Water Level <br /> Remarks <br /> CONTRACTORSSTATEMENT <br /> The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or <br /> pump installation described he on; that he ha read the s atement made hereon; knows the content <br /> thereof, and that t is own k wle <br /> Signature License NO. 711 <br /> ARTHUR WALTON A J DRILLING CO <br /> State of Colorado, County of —"a2'� SS <br /> Subscribed and sworn to before me this --Z2 day of , 19 7 <br /> My commission expires .lvly 9, Iy;' <br /> My Commission expires: 19 - <br /> Notary Public__ <br /> FORM TO BE MADE OUT t QUA-DRUPL{CATE-. WHITE FORM must be an original copy on hoth 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 />