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PUMP INSTALLATION REPORT <br /> <br />Pump Make <br />Type <br />Powered by HP <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 />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,fr~'ithe yyme is t~ of his own knowledge. <br />~ ~ SLJ / I .rt <br />Signatu // r ~ ~ ~ License No. ,Llo1~? <br />State of li/r ,County of c~c7.epn0. SS <br />i ti >oc:ocaocr.~c:~ooc <br />Subsc: ibed and sworn to betore me this day of L~our..aloer , lg onna L Crimm • Notary Public <br />p r~ County of ,; :!.- „c;.cc of <br />My Commission expires: ~t~oc un r~( aq 19 SL7- . Natrona ~. ~c+y~minp <br />. ~~ <br />Notary Public J1,I,ynvr`, M Co~~+~r~Fet«i9~1~9t8~4G <br />FORM TO BE MADE OUT IN OUADR UPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copes must be Bled with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Griller. <br />