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PUMP INSTALLATION REPORT <br />Pump Make NSA <br />Type <br />Powered 6y <br />Pump Serial No. <br />Motor Serial No. <br />Date InstalleD <br />Pump Intake Deptfl _ <br />Remarks <br />WELL TEST DATA WITH PERMANENT PUMP <br />Date Tested <br />Static Water Level Prior to Test <br />Le^~th of Test <br />Hours <br />Sustained yield (Metered) 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 t at a wane is true,af his own knowledge. <br />Signatu <br />License No. //v2R <br />~ // <br />Wy 0 <br />County of _ .cr Tree <br />State of g SS <br /> <br />Subscribed and sworn to before me this ~ day of f~oucmbar f g gnna L Cr:ma, - \orty Public <br /> <br />My Commission expires:- ~~~~ ~ <br />9 , 79 ~- . County of <br />Natrona ~ ,, ~,. „rm of <br />~: Wypming <br />~~, <br />n ,~ <br />Notary PUbIIC ~ c~>J~ ~ My Commi., <br />.~oor•cs a `on E::paes FcS. :9, 1984 <br />c:scac»cao.:aooc <br />HP <br />FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copws must be I~ted with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for tha Oriiler. <br />