Form Sw-262 - Water Well Pump Installation Report - West Virginia

Download a blank fillable Form Sw-262 - Water Well Pump Installation Report - West Virginia in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Sw-262 - Water Well Pump Installation Report - West Virginia with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Rev 3/08

DATE OF PUMP

FORM SW-262

STATE OF

INSTALLATION

THIS REPORT MUST BE

ST/CO USE ONLY

WEST VIRGINIA

SUBMITTED WITHIN 30 DAYS

DATE RECEIVED

MM DD

WATER WELL

AFTER INSTALLATION IS

___

COMPLETED

MM DD

PUMP

___ ___ ___

WATER WELL PERMIT

FILL IN THIS FORM

INSTALLATION

NO.

COMPLETELY

REPORT

PLEASE PRINT OR TYPE

DW-________________

PUMP INSTALLATION LOCATION

Owner:

LAST NAME

FIRST NAME

STREET/ROAD

COUNTY

ZIP CODE

AREA NAME/LOCATION:

WATER SYSTEM USE:

Potable

Public Water Supply

Geothermal

Industrial

Commercial

Dewatering

Irrigation

Test/Exploratory

Other ___________________

PUMPING EQUIPMENT

INSTALLATION DETAILS (CONT.)

Type Pump:

Submersible

Jet

Other (specify)

Pitless:

Pitless Adapter

Pitless Unit

Pump Manufacturer:

Pitless Manufacturer:

Pump Model:

Pitless Model:

Method of Cutting Hole in Casing for

INSTALLATION DETAILS

Pitless:

Storage Tank Model:

Well Diameter ______________inches

Check Valves Locations:

Well Depth _______(Ft)

Well Disinfected:

Yes

Static Water Level (from surface): ____________(Ft.)

By Whom:

Depth of pump: ___________________________(Ft.)

Riser Pipe: Material________________________

Pressure Rating__________________(psi)

COMMENTS BY INSTALLER

I hereby certify that this well has been constructed in accordance with state rules and that the information presented herein is accurate and complete to the

best of my knowledge.

Pump Equipment Installed by :

Property Owner Name (Print)_________________________________________

Owner Signature _______________________________________

Pump Installation Test Passed on ________/_______/_______

Company Name ________________________

WV Contractor No. ____________________

Business Franchise Number_______________

Master Well Driller Certification No. _________________ or Pump Installer Certification No. _________________________________________

Master Well Driller (print) ________________________ Master Well Driller Signature _____________________________________________

Pump Installer ( print) ____________________________ Pump Installer Signature__________________________________________________

SITE SUPERVISOR (SIGNATURE OF DRILLER OR JOURNEYMAN RESPONSIBLE FOR SITEWORK IF DIFFERENT FROM MASTER