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Pump Make S/ ~- /l y ~~ <br />Type S~6MEhSi d ~~ <br />~p Serial No. <br />Motor Serial No. <br />Date Installed ~~~ ~O -___/ <br />' `N i <br />Pump Intake Depth J <br />Remarks <br />WELL TEST DATA WITH PERMANENT PUMP <br />Date Tested ~~ - ~ ~ ~ 77 <br />ai/ <br />Static Water Level Prior to Test <br />Length of Test ~ Hours <br />stained yield (MatoFC~) ~~- GPM <br />i <br />mping 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 <br />License No. <br />State of Colorado, C only of ~~ =~-•"-~-~~ SS <br />Subscribed and sworn to bofpfe Lne this • ~ a day of ti! e-~~~-/-~, 7g ~, <br />Y 0!pm:::1~ ~ e"inr^s Oci~','c[[ 1" l~~g <br />My Commission expir~e4s: / , 19 JI ~J! <br />• Notary Public ~r ' /J''~~~ ~ ~-~K~~f/ <br />FORM TO BE MADE OUT IN OUADR UPLICATE: WMI TE FORM mutt M an or~pind copy o~ bolh f:d~a end fiynFtl. <br />WHITE AND GREEN copier moil De Lod w~lh ,he State Enpin<~r. PINK COPY ii lo. the Ownu and VELLOL7 COPY a log N~ DrnNr. <br />