Filter
Top Products
RMA No. _____________
INSTALLER’S NAME ___________________________ OWNER’S NAME _________________________________
ADDRESS ___________________________________ ADDRESS ______________________________________
CITY __________________ STATE_____ ZIP________ CITY ____________________ STATE_____ ZIP________
PHONE (____) _____________ FAX (____) _________ PHONE (____) _____________ FAX (____)____________
CONTACT NAME ______________________________ CONTACT NAME ________________________________
WELL NAME/ID _______________________________ DATE INSTALLED __________ DATE FAILED__________
WATER TEMPERATURE ________ °F or ________ °C
Motor:
Motor No. __________________ Date Code ___________________ hp ________ Voltage _________ Phase ______
Pump:
Manufacturer _________________ Model No. _________ Curve No. _________ Rating: ______ gpm@______ft TDH
NPSH Required ___________ ft NPSH Available_________ ft Actual Pump Delivery__________gpm@ ______ psi
Operating Cycle ______________ON (Min/h) _________________ OFF (min/h) (Circle Min or h as appropriate)
YOUR NAME ___________________________________________________________ DATE ______/______/______
WELL DATA:
Total Dynamic Head ________________ft
Casing Diameter __________________ in
Drop Pipe Diameter ________________ in
Static Water Level __________________ft
Drawdown (pumping) Water Level _____ft
Check Valves at _________ & _______ &
_________ & _______ ft
❑ Solid ❑ Drilled
Pump Inlet Setting _________________ft
Flow Sleeve: ___No____Yes; Dia. _____in
Casing Depth ______________________ft
❑ Well Screen ❑ Perforated Casing
From_____to_____ft & ______to______ft
Well Depth ________________________ft
TOP PLUMBING:
Please sketch the plumbing after the well head
(check valves, throttling valves, pressure tank, etc.)
and indicate the setting of each device.
Form No. 2207 8/00
Submersible Motor Installation Record