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GENERAL PURPOSE WELL INVESTIGATION FORM <br />Reported By: <br />Well Owner Name & Address: <br />Well Location: <br />GPS Position: <br />Phone: <br />Phone: <br />Contract 31748 <br />Comments: <br />Attach photos <br />Version 1.7 <br />1/11/16 <br />-7- <br />P77 <br />(Latitude) <br />(Longitude) <br />Date of Inspection: <br />Observed By: <br />Well Diameter: <br />Well Depth: _ <br />Well Status: (Check All That Apply) <br />Accessible By: <br />Well Head: <br />Condition: <br />Action: <br />❑ Foot <br />❑ Visible <br />❑ Capped <br />❑ Left as Found <br />❑ Vehicle <br />❑ Buried <br />❑ Valved <br />❑ Temp Plug <br />❑ Boat only <br />❑ Discharge visible only <br />❑ Leaking <br />❑ Temp Repair <br />❑ Not accessible <br />❑ Under power lines <br />❑ Flowing <br />❑ Flagged or staked <br />❑ Unable to locate <br />❑ Other <br />Flow upon arrival <br />gpm <br />Flow wide open <br />gpm <br />Flow as left <br />gpm <br />Comments: <br />Attach photos <br />Version 1.7 <br />1/11/16 <br />-7- <br />P77 <br />