Fillable CHECK-OUT SHEET WATER WELL (Information Technology Services)

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CHECK-OUT SHEET WATER WELL (Information Technology Services)

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The CHECK-OUT SHEET WATER WELL (Information Technology Services) form is 2 pages long and contains:

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  • 14 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Information Technology Services

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First Name Last name
County Tract - Field
Contract Number
Well Site Coordinates (decimal degrees): LAT LONG
Copy of Well Construction Record (GW-1 or applicable county form)
Copy of state and/or any required county permit, if applicable N/A
Adequate wellhead protection measures installed
Berm and/or diversion completed (if required)
N/A
Covering over well head and pressure tank adequate to prevent freezing
Plumbing connected to a suitable pressure tank (if applicable) N/A
Wiring from pressure switch to pump completed (if applicable) N/A
Casing is a minimum of 1 foot above the ground surface
A method for distributing the water from the well is available
Well driller found on NC Certified Well Contractor list:
http://www.wellcontractors.nc.gov/web/eh/find-contractor
Please check each box to confirm that the following items were field-verified and that the water well/pump installation has
been installed at the planned location, properly tagged with ID plate(s) as required by NC Well Construction Standards (15A
NCAC 02C).
CHECK-OUT SHEET
WATER WELL
COOPERATOR INFORMATION
WELL/PUMP INSTALLATION CHECK-OUT
Drilling Contractor’s name: Drilling Contractor’s certification number:
Total depth of well: Casing depth: Inside diameter of casing:
Static Water Level: Date Level Measured: Inside diameter of casing:
Date well was completed: Sate Permit Number (if applicable)
Pump Installation Contractor’s name: Pump Installation Contractor’s certification number:
Date pump was installed: Depth of pump intake: Pump horsepower:
Name Agency
Signature Date
TECHNICAL REPRESENTATIVE
WELL CONTRACTOR IDENTIFICATION PLATE INFORMATION
Yield (GPM)
Screened Intervals
(if applicable)
Gravel/Sand Pack
(if applicable)
PUMP INSTALLER IDENTIFICATION PLATE INFORMATION
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CHECK-OUT SHEET WATER WELL (Information Technology Services)

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Completed 14 August 2020

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