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TRUE COPY <br /> EHTIEICATIOM ON LAST PAGE <br /> J.R.SMITH,CLERK <br /> Contract 31748 <br /> GENERAL PURPOSE WELL INVESTIGATION FORM <br /> Reported By: Phone: <br /> Well Owner Name&Address: <br /> Phone: <br /> Well Location: <br /> GPS Position: <br /> (Latitude) (Longitude) <br /> Date of Inspection: Observed By: <br /> Well Diameter: Well Depth:_ <br /> Well Status: (Check All That Apply) <br /> Accessible By: Well Head: Condition: Action: <br /> ❑ Foot ❑ Visible ❑ Capped ❑ Left as Found <br /> ❑ Vehicle ❑ Buried ❑ Valved ❑ Temp Plug <br /> ❑ Boat only ❑ Discharge visible only ❑ Leaking ❑ Temp Repair <br /> ❑ Not accessible ❑ Under power lines ❑ Flowing ❑ Flagged or staked <br /> ❑ Unable to locate ❑ Other <br /> Flow upon arrival gpm <br /> Flow wide open gpm <br /> Flow as left gpm <br /> Comments: <br /> Attach photos <br /> er.•;iott 1., <br /> - 7- <br />