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Azwater. gov Pump Installation Completion Report FILE NUMBER Review instructions prior to completing form in black or blue ink. Arizona Department of Water Resources Information Management Unit P. O. Box 33589 Phoenix AZ 85067-3589 602 771-8627 800 352-8488 www. The registered well owner should file this report with the Department within 30 days following installation of pump equipment. WELL REGISTRATION NUMBER 55 PLEASE PRINT CLEARLY SECTION 1. REGISTRY INFORMATION Well Owner Location of Well FULL NAME OF COMPANY ORGANIZATION OR INDIVIDUAL WELL LOCATION ADDRESS IF ANY TOWNSHIP N/S RANGE E/W SECTION MAILING ADDRESS 160 ACRE 40 ACRE CITY / STATE / ZIP CODE COUNTY ASSESSOR S PARCEL ID NUMBER MOST RECENT BOOK MAP PARCEL CONTACT PERSON NAME AND TITLE COUNTY WHERE WELL IS LOCATED TELEPHONE NUMBER FAX SECTION 2. EQUIPMENT INSTALLED DATE PUMP INSTALLED Pitless Adaptor CHECK ONE SEE INSTRUCTIONS FOR DEFINITION Yes No Was a pitless adaptor installed Pump Type CHECK ONE IF YES DEPTH BELOW GROUND LEVEL THE DEVICE WAS INSTALLED Air Lift Bucket Centrifugal Jet Piston Rotary Submersible Turbine Other please specify RATED PUMP CAPACITY Feet Power Type Diesel Engine Electric Motor Gasoline Engine Hand Natural Gas Windmill HORSE POWER RATING OF MOTOR Gallons Per Minute SECTION 3. PUMP TEST Pump Test Data Method of Discharge Measurement Method of Measuring Water Level DATE WELL TESTED STATIC WATER LEVEL A Feet Below Land Surface PUMPING WATER LEVEL B DRAWDOWN B A TEST PUMPING RATE DURATION OF PUMP TEST Minimum 4 Hours Bailer Bucket Barrel Stopwatch Current Estimated Air Lift Gauge Meter Orifice Volume Weir Flume Air Line Electric Measuring Line Sounder Steel Tape Hours TOTAL PUMPING LIFT FOR FLOWING WELL MEASURED SHUT IN HEAD FT PSI I HEREBY CERTIFY that the above statements are true to the best of my knowledge and belief according to A. The registered well owner should file this report with the Department within 30 days following installation of pump equipment. WELL REGISTRATION NUMBER 55 PLEASE PRINT CLEARLY SECTION 1. REGISTRY INFORMATION Well Owner Location of Well FULL NAME OF COMPANY ORGANIZATION OR INDIVIDUAL WELL LOCATION ADDRESS IF ANY TOWNSHIP N/S RANGE E/W SECTION MAILING ADDRESS 160 ACRE 40 ACRE CITY / STATE / ZIP CODE COUNTY ASSESSOR S PARCEL ID NUMBER MOST RECENT BOOK MAP PARCEL CONTACT PERSON NAME AND TITLE COUNTY WHERE WELL IS LOCATED TELEPHONE NUMBER FAX SECTION 2. WELL REGISTRATION NUMBER 55 PLEASE PRINT CLEARLY SECTION 1. REGISTRY INFORMATION Well Owner Location of Well FULL NAME OF COMPANY ORGANIZATION OR INDIVIDUAL WELL LOCATION ADDRESS IF ANY TOWNSHIP N/S RANGE E/W SECTION MAILING ADDRESS 160 ACRE 40 ACRE CITY / STATE / ZIP CODE COUNTY ASSESSOR S PARCEL ID NUMBER MOST RECENT BOOK MAP PARCEL CONTACT PERSON NAME AND TITLE COUNTY WHERE WELL IS LOCATED TELEPHONE NUMBER FAX SECTION 2. EQUIPMENT INSTALLED DATE PUMP INSTALLED Pitless Adaptor CHECK ONE SEE INSTRUCTIONS FOR DEFINITION Yes No Was a pitless adaptor installed Pump Type CHECK ONE IF YES DEPTH BELOW GROUND LEVEL THE DEVICE WAS INSTALLED Air Lift Bucket Centrifugal Jet Piston Rotary Submersible Turbine Other please specify RATED PUMP CAPACITY Feet Power Type Diesel Engine Electric Motor Gasoline Engine Hand Natural Gas Windmill HORSE POWER RATING OF MOTOR Gallons Per Minute SECTION 3.

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