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WELL WATER SOURCES

15.

Are there potential sources of pollution in close proximity to the well?

□ Yes     □ No     □ Not Sure

     If yes, explain:  ____________________

     _________________________________

     _________________________________

16.

What is the depth of the well? _____ feet □ Not Sure

17.

Is the drawdown being measured?  

□ Yes     □ No

If “Yes” what is the depth? _______

□ Not Sure

18.

Does the well pump rate fluctuate?

□ Yes     □ No     □ Not Sure

19.

Are there any changes in water quality?

□ Yes     □ No     □ Not Sure

20.

What conditions cause changes to water quality? __________________________

_________________________________

_________________________________

21.

Does the well casing extend at least 12 inches above the floor or grade?

□ Yes     □ No

22.

Is the well properly sealed?

□ Yes     □ No    □ Not Sure

23.

Does the well vent terminate 18 inches above ground/floor level or above flood level with the return bend screened and facing downward?

□ Yes     □ No    □ Not Sure

24.

Is backup power provided for emergency situations such as flood, ice storm, tornado, etc?

□ Yes     □ No    □ Not Sure

25.

Is lightning protection provided?

□ Yes     □ No    □ Not Sure

26.

Do you have on file plans, specific-ations, and maps for the water system, including any expansions or modific-ations?

□ Yes     □ No    □ Not Sure

27.

Are all chemicals and lubricants approved for water supplies?  (For example:  food grade lubricating grease and oils)

□ Yes     □ No    □ Not Sure

28.Do chemicals and lubricants meet the standards of the American National Standards Institute (ANSI) and the National Sanitation Foundation (NSF)? □ Yes     □ No    □ Not Sure

29. Are the facilities adequately secured?

□ Yes     □ No    □ Not Sure

30.

Is the site subject to flooding?

□ Yes     □ No    □ Not Sure

31.

Is surface runoff diverted?

□ Yes     □ No    □ Not Sure

32.

Is the emergency spill response plan adequate?

□ Yes     □ No    □ Not Sure

33.

Does your county have an approved water supply plan?

□ Yes     □ No    □ Not Sure

34.  Date of last sanitary survey?_________

□ Not Sure

Comments: __________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

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____________________________________

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