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PUMP INSTALLATION REPORT <br />Pump Make ~~ <br />Type <br />Powered by <br />Pump Serial No. _ <br />Motor Serial No. _ <br />Date Installed <br />Pump Intake Depth <br />Remarks <br />HP <br />WELL TEST DATA WITH PERMANENT PUMP <br />Date Tested _~/A <br />Static Water Level Prior to Test <br />Le^~th of Test <br />Sustained yield (Metered) <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(tha the me Is t~r of his own knowledge. <br />SignatlhP~~, ~' 2~~+~~ ~ inrn / ~2~4 lnc License No. ~l_o~~ <br />State of ley /, County of _ /U.41'~~Anov ~ SS <br />~boc>cac; oc.~otsoc>o< <br />Subsc: ibed and sworn to betore me this ~ day of ~)~vambu , 19 onna L Critnm -Notary Vublic <br />County of „rare of <br />My Commission expires: aA 19gJ` _ . Nanoae ury„mb,t <br />~~- <br />My Cumm!ss!on E::p¢cs Feb.?9, 1984 <br />Notary Public J~yrvm 'rx>tx>oo«~«>Qx <br />Hours <br />GPM <br />FORM TO BE MADE OUT IN OUADRUPLICAT E: WHITE FORM must be an original ropy on both sides and signed. <br />WHITE AND GREEN copies must be tiled with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Griller. <br />