Pump Installer Report Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.A. WELL AND OWNER INFORMATIONName *Property Owner NameAddress *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateWell Location 911 AddressCCGCD Well # *District Well NumberLatitude *Well Location LatitudeLongitude *Well Location LongitudeB. PUMP INSTALLER'S INFORMATIONCompany Name *Company NameInstaller's Name *Licensed Installer's NamePhone Number *Company Phone NumberEmail Contact *Company Email AddressCompany Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateLicense Number *TDLR License NumberC. WELL EXEMPTION STATUSSelect One *Domestic and/or Livestock Well NOT equipped to pump greater than 17.36 GPM NO METER PERMITTEDDomestic and/or Livestock Well equipped to pump greater than 17.36 GPM NO METER PERMITTEDDomestic and/or Livestock Well capped at 5 GPM NO METER PERMITTEDOther Well Type NOT equipped to pump greater than 17.36 GPM METER REQUIREDOther Well Type equipped to pump greater than 17.36 GPM METER REQUIREDD. INSTALLED WELL / PUMP INFORMATIONCasing Size (in) *Pump Depth *Pump Motor (HP) *Meter Brand *If meter is requiredWell Depth *Pump Diameter (in) *Voltage *Meter Serial # *If meter is requiredPump/Motor Brand *Number of Stages *Phase *Meter ReadingIf meter is requiredPump Model *Pump Discharge (in) *Production Rate (gpm) *Installation Date *If production was restricted, please explain how and with what equipment *Enter none if not restricted.E. SIGNATUREBy signing this form, I declare that the information provided in this form is true and correct, to the best of my knowledge and belief. I hereby certify that this well was equipped by me or under my direct supervision. Furthermore, I am familiar with all pertinent requirements contained in the Cow Creek Groundwater Conservation District Rules. I agree and acknowledge that if the information I have provided changes in the future, it is my responsibility to provide the new information to the District. I understand that a change in this information may result in additional requirements. Signature * Clear Signature Pump Installer's SignaturePrinted Name *Date *Submit
