2011-09-26_PERMIT FILE - C1981012A ‎(4)‎

• Permit No: C1981012A
• IBM Index Class Name: Permit File
• Doc Date: 9/26/2011
• Section_Exhibit Name: EXHIBIT 11 WATER WELL INFO PART 3
• Media Type: D
• Archive: Yes

~i:'~rPF1MP~NSTALLATION REPORT
Pump ~MaJFej*•
TypE .
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Pump Serial No.
Motor Serial No.
Date Installed
Pump Intake Depth _
Remarks
WELL TEST DATA WITH PERMANENT PUMP
Date Tested
Static Water Level Prior to Test
Length of Test ~ ~ Hours
Sustained yield7Metered) ~ GPM
Pumping Water Level
Remarks
CONTRACTORS STATEMENT
The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or
pump installation described hereon; that he has read the statement made hereon; knows the content
thereof, and,that the same is true of his own knowledge.
Signature
State of Colorado, Gounty of
SS
p~ / 1
Subscribed and sworn to before me thisoGEi: day of «'m %~ , 19
My Commission expires: ~ U _ , 1g
Notary Public d~/~Q~ A- - 'O
License No. f-~-er-
•
FORM TO BE MADE OVT IN OUAORUP LICATE: WHITE FORM must be an original copy on both s~tles and signed.
WHITE AND GREEN Bowes mart be l~letl with the State Engineer. PINK COPY is for the Ownw. and VEL l rn•~ rnpY• ~. In. rh. n.ai.,