Property Transfer Well(s) and Pressure System(s) Inspection
Form 3300-221 (R 10/14)
State of Wisconsin
Department of Natural Resources
dnr.wi.gov
Notice: Pursuant to ch. 280, Wis. Stats., and ch. NR 812, Wis. Adm. Code, this form shall be used to document any well and pressure system inspection
conducted as part of a property transfer. Inspections are voluntary, and well owners are not required to bring systems into compliance as a result of the
inspection. Inspectors must provide the completed form to the requester of the inspection. Do not send forms to DNR.
Contact Information
Inspection Requested By Telephone Number
Mailing Address City State ZIP Code
Owner's Name Telephone Number
Mailing Address City State ZIP Code
N
Property Location
Grid or Street Address or Road Name and Number (if available)
City ZIP Code
Township
E/W
Unique Well Number
of the
County of Water System Location
Gov't Lot # ¼
¼
Section Town Range
E/W
N
Identified noncomplying features are noted below with a check mark.
Known Noncomplying Features
Unused Well Should be Filled and Sealed
Stovepipe or Thin-Walled Casing
Dug Well
Unprotected Buried Suction Line
Alcove (Subsurface Pumproom) or Pit
Non-Walkout Basement or Below-Grade Crawl Space Well
Poor Casing Condition (Badly Corroded or Cracked)
Contaminant Source less than minimum separation distance
from well:
Well in Floodway or Flood Fringe
Well at Risk from Localized Flooding
Cross-Connection
Driven Point Well (installed after 1-31-1991) without
construction report
Nonpressure Conduit
Hand Pump
Offset Pump or Piping Height < 12" Above Floor
Yard Hydrant
Materials for Pump and Supply Piping
Flowing Well Installation
Check Valve Location
Well Cap or Seal
Casing Height
Electrical Wires Not Properly Enclosed in Conduit
Sample Faucet is Missing or Incorrect
Casing less than 6" in diameter for a well in limestone,
dolomite, shale, quartz or granite
Health/Safety Hazard
1.
2.
3.
4.
8.
7.
6.
5.
9.
13.
12.
11.
10.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Comments
Pre-1991 Driven Point Pipe Depth < 25 feet
Pre-1979 Two-Wire Submersible Pump
Evidence of Some Corrosion on Well Casing Pipe
Well Located in Special Well Casing Depth Area
Well Construction Report Not on File or Unlocatable
Other:
Inaccessible or Difficult Location for Future Well Work
Inaccessible or Difficult Location for Future Pump Work
Non-Vermin-Proof Well Cap or Well Seal
More comprehensive or additional research is needed regarding:
Based on my personal inspection of the real property, the well(s) and pressure system(s):
Complies
Does not comply
with Wis. Adm. Code.
Signature of Licensed Water Well Driller or Pump Installer Individual License #
This form lists the visible conditions of the well(s) and pressure system(s) on the property at the time of inspection and does not imply or
give any guarantee.
Telephone NumberDate
an unused well floodways/floodplains contaminant sources other:
