Virginia Water Well Inspection Checklist

CONTRACTOR INFORMATION

• Well contractor name

• Date and Time

  Date

• Prepared by

CLIENT INFORMATION

• Name

• Phone

• Email

• Mailing Address
  Address
• Well location, if different from above
  Address

• Referral source

  Select Virginia Cooperative Extension Drinking Water Clinic Well drilling contractor Friend or Neighbor Advertisement Website

  • Virginia Cooperative Extension Drinking Water Clinic
  • Well drilling contractor
  • Friend or Neighbor
  • Advertisement
  • Website

• Country/Name/Source

• Other (please specify)

• Ownership of property

  Select Own this property Rent this property Plan to sell this property Consider purchasing this property

  • Own this property
  • Rent this property
  • Plan to sell this property
  • Consider purchasing this property

• Client problems with / concerns about water well or pump (specify)

• 1. Well construction

  Drilled

  Bored

  Coastal plain or sand

• Other (Specify)

• 2. Availability of well records? (attach a copy to the report)

• Well Completion Report

• a. Year constructed

• b. Depth ft

• c. Static water level ft

• d. Well class

  III

  IIIC

  IIIB

  IV

• Water Test (date of most recent)

  Date

• Maintenance Records (date of last service)

  Date

• Shock Chlorination (date of last chlorination)

  Date

• Other (please specify)

  Date
• 3. Well location on the property (provide GPS coordinates, a description, or sketch)
  Address

• 4. Inspection of wellhead and casing (check all that apply)

  Select Buried well – pitless adaptor Casing adapter accessible Well in pit – pitless adaptor Wellhead visible above ground Casing at least 12” above ground surface Area around well casing burmed or sloped to prevent pooling or runoff of surface water around the wellhead Cracks in or corrosion/damage to casing Voids or spaces around casing

  • Buried well – pitless adaptor
  • Casing adapter accessible
  • Well in pit – pitless adaptor
  • Wellhead visible above ground
  • Casing at least 12” above ground surface
  • Area around well casing burmed or sloped to prevent pooling or runoff of surface water around the wellhead
  • Cracks in or corrosion/damage to casing
  • Voids or spaces around casing

• 5. Inspection of well cap (check all that apply)

  Select Approved sanitary, sealed, water-tight well cap in place; bolts tight and secure Approved sanitary, sealed, water-tight well cap, but needs repair or replacement Old, conduit-style well cap (“shoe-box” fit; unsealed)

  • Approved sanitary, sealed, water-tight well cap in place; bolts tight and secure
  • Approved sanitary, sealed, water-tight well cap, but needs repair or replacement
  • Old, conduit-style well cap (“shoe-box” fit; unsealed)

• Presence of insects or other vermin around well cap (specify)

• 6. Permanent structures within 10 feet of the wellhead?

  Yes

  No

• If yes, specify

• 7. Well easily accessible for future repairs and service?

  Yes

  No

• If, No (specify)

• 8. Based on the site inspection, does the well meet the minimum distance from contamination sources as outlined in the Virginia Well Water Regulations?

• Structure or Topographic Feature | Class IIIC or IV | Class IIIA or B

• Building foundation / 10’ / 10’

  Yes

  No

  N/A

• Building foundation (termite treated) / 50’ / 50’

  Yes

  No

  N/A

• House sewer line / 50’ / 50’

  Yes

  No

  N/A

• Sewer main or system / 50’ / 50’

  Yes

  No

  N/A

• Pretreatment system (e.g., septic tank, aerobic unit) / 50’ / 50’

  Yes

  No

  N/A

• Sewage disposal system / other source (drain field, underground storage tank, barnyard, feed lot) / 100’ / 50’

  Yes

  No

  N/A

• Cemetery / 100’ / 50’

  Yes

  No

  N/A

• Stream / 100’ / 50’

  Yes

  No

  N/A

• Comments / other nearby sources of potential contamination

• 9. Are potentially hazardous materials stored near the well?

  Yes

  No

• If yes, specify

  Select Hazardous materials are stored in sealed, original, and labeled containers Hazardous materials are stored on impervious surface Hazardous materials are properly disposed of at household collection days Hazardous materials are never dumped on the ground, down a storm drain, or in an abandoned well or sinkhole Hazardous products are not stored within 50 feet of the well Machinery is fueled on a concrete floor; spills are cleaned up immediately

  • Hazardous materials are stored in sealed, original, and labeled containers
  • Hazardous materials are stored on impervious surface
  • Hazardous materials are properly disposed of at household collection days
  • Hazardous materials are never dumped on the ground, down a storm drain, or in an abandoned well or sinkhole
  • Hazardous products are not stored within 50 feet of the well
  • Machinery is fueled on a concrete floor; spills are cleaned up immediately

• 10. According to the homeowner and/or well completion report, are there any abandoned wells on the property?

  Yes

  No

• Have they been properly abandoned or do they currently pose a threat to groundwater quality or other wells nearby? (specify)

  Yes

  No

• 11. Inspection of pump

• a. Type of pump

• b. Horsepower of pump

• c. Voltage rating

• d. Properly grounded

  Yes

  No

• 12. Inspection of pressure tank

• a. Are there any leaks or corrosion?

  Yes

  No

• b. Size of the pressure tank

• c. Properly plumbed?

  Yes

  No

• d. Properly wired?

  Yes

  No

• e. Has bladder been serviced?

  Yes

  No

WATER TESTING

• 1. Water treatment devices

• a. Are there water treatment devices installed in the home?

  Yes

  No

• b. What types of devices are installed?

• 2. According to homeowner records, has water been tested recently?

  Yes

  No

• (summary of results/problems)

• 3. Recommended water testing

  Select None Bacteria Nitrate pH Metals VOCs Other

  • None
  • Bacteria
  • Nitrate
  • pH
  • Metals
  • VOCs
  • Other

• Other Specify

• 4. Water sample collected?

  Yes

  No

• Date and TIme

  Date

• Date results ready

  Date

• Summary and Recommendations from Visual Inspection

• Contractor's Name and Signature

  Sign

• 1. Voltage (volts)

• Fused properly

• System components are compatible

• 2. Amperage ( amps/amperes)

• Appropriate for pump rating

• 3. Pre-charge on the pressure tank

• 4. Pump cut-in pressure

• 5. Pump cut-out pressure

• 6. Pressure differential

• 7. Correct drawdown for tank size provided?

  Yes

  No

• 8. Valves working properly?

  Yes

  No

• 9. Condition of pressure switch / sensor

  Good

  Needs replacement

• 10. Relief valves installed and sized correctly?

  Yes

  No

• 11. Amount of time for the pump to go from the low limit to the high limit with no water running in the house

• Summary from Technical Inspection

• Recommendations for Additional Diagnostics or Repairs

• Contractor's Name and Signature

  Sign