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PUMP INSTALLATION REPORT <br />'ump 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 <br />Static Water Level Prior to Test <br />Length of Test 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 that the same is true of his own knowledge. <br />Signature <br />State of Coloraao, ~ounry of <br />License No. <br />SS <br />Subscribed and sworn to before me this 18 day of Jene 19 73 <br />My Commission expires: 12-8 19 74 <br />Notary Public h"`"''r'°""a~- ~" ' ~"~-- <br />~Iaraaerire ~.nooeiaa <br />U <br />FORM TO BE MADE OUT IN OUADR UPLIC4 TE: WHITE FORM must 6e an original copy on both sltles and signed. <br />WHITE AND GREEN co D.es muss be Bled w~cn the State Enameer. PINK COPY n 1nr the Owna. and VELLOW COPY is /o. the Orller <br />