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PUMPINSTALLATION REPORT <br />Pump Make '~~A <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^~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 a the me is tr f his own kno ledge. <br />Signatu 11 ~ ~ License No. //„~,r~ <br />State of 6LJy County of ,~~/annc. SS <br />Subscribed and sworn to before me thisQlh day of -Jcv~mbt,- , 19 0~ ~c«~n~~`,:~` <br />Count o! t~' <br />y ,r^j sate of <br />My Commission expires: r'w~ , 19 ~-_ . Na<tona +~.' w omin <br />`~ r s <br />Notary Public ~ A,.t,,,.,n, M C":twti~:mc`,«`~oc~'taecic <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 eop~es must be filed with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Griller. <br />