Source Flow Pump
Well Inspection Report
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Site Location
*
General
Information
Inspection Requested By
First Name
Last Name
Company
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Owner
Phone Number
Please enter a valid phone number.
Email
example@example.com
Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Well Data
Photo
From:
Well Completion Report
Field Observation During Inspection
Not available at time of inspection
Well #/ID
Type
Drilled
Dug
Bored
Not Available
Well Details
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Well Pump Data
Photo
From:
Well Completion Report
Field Entry During Inspection
Not available at time of inspection
Pump Type
Please Select
Submersible
Jet
Hand Pump
Other
Well Pump Details
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Booster Pump Data
Photo
From:
Well Completion Report
Field Entry During Inspection
Not available at time of inspection
Booster Pump Details
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Pressure Tank Data
Photo
From:
Well Completion Report
Field Entry During Inspection
Not available at time of inspection
Pressure Tank Details
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Visual Inspection
Wellhead, casing, cap, and above-ground components
Photo
50 feet or more setback from septic tanks, livestock yards, and septic leach fields.
Yes
No
100 feet or more setback from petroleum tanks, pesticide and fertilizer storage
Yes
No
250 feet or more setback from manure stacks.
Yes
No
The soil around the well is sloped away to prevent puddling around the wellhead and to divert any runoff water from going to the wellhead.
Yes
No
Are there any voids in the soil around the top of the wellhead which could allow water to travel down the borehole to the aquifer?
Yes
No
Comments
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Wellhead Components
Wellhead casing, seal, vent, piping, and condition
Casing Material
Please Select
PVC
Galvanized Steel
Carbon Steel
Stainless Steel
Other
Does the well casing extends 12 or more inches above grade?
Yes
No
Does the wellhead have any visible holes, cracks, corrosion, of physical damage.
Yes
No
Is the top of the wellhead properly covered with a well cap or seal to prevent contaminants from entering the well?
Yes
No
Is the well Cap weather-tight and vermin proof?
Yes
No
Comments
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Photos
Wellhead
Wellhead Structure, Cover, or Seal.
Well Casing
Well Cap
Well Vent
Wellhead Discharge piping
Photo
Photo
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Electrical Components
Power Supply
Voltage/Amperage
Electric Meter
Conduit
Junction Box
Pressure Switch
Electrical Connections
Breaker Panel
Electrical Equipment Condition
Very Good
Good
Needs Attention
Not Functioning
Not Inspected
N/A
Conduit
Junction Box
Pressure Switch
Electrical Connection
Tank Float
Booster Pump
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Inspection Summary
Visual Inspection Summary
Very Good
Good
Needs Attention
Not Functioning
Not Inspected
N/A
Casing
Wellhead
Electrical
Storage Tank
Pressure Tank
Booster Pump
Piping, fittings, valves
Comments
Inspector Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Signature
*
Submit
Submit
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