Water Well Inspection Survey
Please complete this survey to document your water well inspection. Use the structured questions below to provide clear, accurate information about the well's condition and any issues observed.
Well Location or ID
*
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Wellhead Condition
*
Excellent
Good
Fair
Poor
Casing and Cap Integrity
*
No visible issues
Minor cracks or corrosion
Significant damage or missing cap
Water Clarity
*
Clear
Slightly cloudy
Cloudy or discolored
Presence of Odor
*
No odor
Mild odor
Strong odor
Pump Operation
*
Normal
Noisy or irregular
Not operational
Electrical and Safety Devices
*
All functioning
Some issues
Not inspected / Not present
Visible Signs of Contamination or Debris
*
None observed
Minor debris
Major contamination
Inspector Comments or Recommendations
Submit Survey
Should be Empty: