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PUMP INSTALLATION REPORT <br />1 ICI E <br />Pump Make <br />Type <br />Powered by . HP <br />Pump Serial No. <br />Motor Serial No <br />Date Installea <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 -nth 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 f his own knowledge. <br />Signature J License No 9.5 b <br />State of Colorado, County of /R, n - a to w c o SS <br />Subscribed and sworn to betore me this /3' day of �� t. a r y , 19 a . <br />My Commission expires: h// g 19 <br />Notary Public ___"- 4.4L s L_ <br />gia <br />FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Griller. <br />CONE OF <br />DEPRESSION <br />