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WEL <br />Dab <br />Stat <br />Len <br />Susl <br />Pun <br />Rer <br />CONTRACTORSSTATEMENT <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 IGGC e License No. 775 <br />State of Colorado, County of Park SS <br />Subscribed and sworn to before me this a day of May 19 75 <br />My Commission xplres. January 14 19 78 . <br />Notary Public/, , <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 Driller. <br />