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Inspection Report
Customer Information
Name
Address
, ,
Appointment Information
Technician Name
Date of Appointment
September 12, 2024
Time of Appointment
Equipment Information
Type(s) of Well
Type(s) of Pump
Well Equipment
Filtration Equipment
Water Quality Test
Water Test Information
Iron Level (in ppm)
pH Level
Hardness Level (in gpg)
Sulfur Odor
Color
Inspection Information
Notes
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Step
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23
- Customer Information
4%
Customer Information
Hidden
Report ID
Name
First
Last
Address
Street Address
City
ZIP / Postal Code
Appointment Information
Technician Name
Date of Appointment
MM slash DD slash YYYY
Time of Appointment
Hours
:
Minutes
AM
PM
AM/PM
Equipment Information
Type(s) of Well
4-Inch Deep Well
2-Inch Deep Well
Shallow Well
Other
Type(s) of Pump
Submersible Pump
Above Ground Pump
Other
Well Equipment
Control Box
Pressure Switch
Bladder Tank
Other
Filtration Equipment
Chlorine Pump
Contact Tank
Flow Switch
Carbon Filter
Water Softener
Other
Water Quality Test
Sample Taken at Well Head
Sample Taken after Filtration
Water Test Information (Sample Taken at Well Head)
Iron Level (in ppm)
pH Level
Hardness Level (in gpg)
Sulfur Odor
None
Slight
Strong
Color
4" Well Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
2" Well Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Shallow Well Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Other Well Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Submersible Pump Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Above Ground Pump Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Other Pump Information
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Control Box
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Pressure Switch
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Bladder Tank
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Other Well Equipment
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Chlorine Pump
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Contact Tank
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Flow Switch
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Carbon Filter
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Water Softener
Photos
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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Other Filtration Equipment
Photos
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Select files
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Condition
In Good Working Condition
Fair
Poor
Notes
Water Test Information (Sample Taken after Filtration)
Iron Level (in ppm)
pH Level
Hardness Level (in gpg)
Sulfur Odor
None
Slight
Strong
Color
Other Information
Technician Notes
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