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PUMPINSTALLATION 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 />WELL TEST DATA WITH PERMANENT PUMP <br />Date Tested <br />Static Water Level Prior to Test <br />Le^nth of Test <br />Hours <br />Sustained yield (Metered) GPM <br />Pumping Water Level <br />Remarks <br /> <br /> <br /> I <br /> <br /> : <br /> <br />~. , <br />:l;'. <br />~% '.+: <br />s.: <br />•~' ~ <br />r' ~ °?fi, ~~~~ <br />% ~ <br />~~ . <br /> <br /> r' ';~ W <br /> - J 3 J WATER <br /> '.~ <br />-;~ W v ~ TABLE <br /> : W <br />~ <br /> J Q <br /> KI N <br /> • ~ <br /> l <br />; <br />. <br /> ~. -3 - -------- <br /> 2~: ~ <br /> - <br /> l` ~ <br /> = I <br />/ <br /> / <br /> <br /> <br /> :'; <br />i <br /> ~~ <br /> LONE OF <br /> ;; '+' C>EPRESStON <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 a he a is tru his own knowledge. ' <br />Signatur I License No. //o?,P <br />State of ~ ,County of ~T~ana SS <br />Q~ti >«~« <br />Subsc: ibed and sworn to betore me this J_- day O{ A~OU Nnptr nn L Crimm -Notary Public <br />:~.. <br />Cotm[y of +:'~ ~tatp of <br />My Commission expires: a 19 ~~ . Natrona Wyu.ntn¢ <br />Notary Pu61ic )~~,m.n~, ~t •S,~o +•E< + es •b. 29, t984 <br />HP <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 copies must be filetl with the State Engineer. PINK COPV is for the Owner and VELLOW COPY is for the Driller. <br />