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Pump Make <br />Type <br />~owered by <br />Pump Serial No. _ <br />Motor Serial No. <br />Date Installed __ <br />Pump Intake Depth <br />Remarks <br />WELL TEST DATA WITH PERMANENT PUMP <br />~~oC~,PQ <br />Date Tested _ <br />Static Water Level Prior to Test <br />Length of Test - <br />~ustained yield (Metered) <br />Pumping Water Levei <br />Remarks <br />Hours <br />GPM <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 thatot~_he same is trueto~f his own knowleffd~ge. <br />Signature ,~, /`/7 ^^~`~>/'" License No. <br />State of Colorado, County of ~~ ~~-~~ ~ SS <br />Subscribed and sworn to before me this /~qq ay of 19 ~G . <br />My Com!nl:slap exro: ~clnher <br />• M~ Commission expires:. 19 _ . <br />Notary Public ~B't-~-~ ~ ,~~~,~ <br />Not. Ins*~lled <br />HP <br />FORM TO eE MADE OUT IN OUADR UP~ICATE: WHITE FORM mull M ~n original coPY on Eotn udn •nd y~gned <br />WHITE ANO GREEN co0~ea mwl be tiled w~lh the Sule Ergineu. PINK COPY n log IM Owmr and VELLO'~/ COPY n Ior IM DnJv <br />