PUMP INSTALLER'S CERTIFIED STATEMENT
HGCD WELL NO.
OWNER NAME
PUMP TYPE
SIZE -HP
YIELD - GPM
DEPTH BOWLS SET FT. BELOW SURFACE
DATE INSTALLED
EXEMPT WELLS
EXEMPT WELLS MUST NOT BE CAPABLE OF PUMPING MORE THAN 17.36 GALLONS PER MINUTE
PERMIT WELLS
PERMIT WELLS MUST HAVE A METER AND NOT BE CAPABLE OF PUMPING MORE GALLONS PER MINUTE THAN AUTHORIZED ON PERMIT WELL APPLICATION
STATEMENT
I HEREBY CERTIFY THAT THIS WELL WAS EQUIPPED BY ME OR UNDER MY SUPERVISION
I HAVE INSTALLED A METER
YES
NO
STATEMENT
EACH AND ALL STATEMENTS HEREIN ARE TRUE
LICENSED PUMP INSTALLER
LICENSE NUMBER
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