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PUMP INSTALLATION 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 />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 />License No. <br />State of Colorado, County of UHaerfano SS <br />Subscribed and sworn to before me this 18 day of Jane ig 73 • <br />My Commission expires: ~ 12-8 1g 74 <br />Notary Pu»lic h- - ~'I ~' `" <br />rgnerite J.Hobeiica <br />FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must Fx an original copy on 6o[h sitles antl signed. <br />WHITE AND GREEN coo~es m~si be filed with [ne Sta [e Ena~neer. PINK CrIPY is fnr [he f)w~.. antl YFI I nw rnrY ~. Inr the D... <br />