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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 lI~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 installs described hereon; that he has read the statement made hereon; knows the content <br />thereof, and hat th sapje is truyo~(~Ffis own knowledge. <br />License No. ~~2~_ <br />State of C~ County of QL~t 7n(Q6thhi2a SS <br />Subscribed and sworn to betore me this day of A~TUembp~ ~' '^"~"'~`~°"""~r'~t <br />na L Cri+nm - Nutary Public <br />~~ <br />County of +" ..ta[e of <br />My Commission expires: S 19g~-. Natrona Wyo[ntnQ <br />~i M omm+ s!on E:: kes Feb. 29,1984 <br />Notary Public ~ wnG__ 1 1~.r/wyr ~,~stv~csaest <br />HP <br />Hours <br />GPM <br />FORM TO BE MADE OUT IN OUAORUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copies must be filed with fhe State Engineer. PINK COPV is for the Owner and VELLOW COPY rs for the Orillar <br />