EP 1110-1-27
27 Jan 00
WELL SERVICE RECORD
Job
Date started
designation
Customer
Date
finished
Job address
City
State
Work
performed
Personnel
Checklist
Surface facility
Pump
Pump removal,
Well
Type of
inspection
test
service, reset
pumping
test::
test (pre-)
Mechanical
Type:
Well
Type of
well
pumping
test:
redevelopment
test (post)
Chemical well
Type:
treatment
Additional
Type:
service
Describe
equipment used
Well: ____________ Dimensions and capacities
Construction
Well
Casing diameter
date
Depth
Original yield
Pump
Screen slot size
type
(state units)
Current yield
Casing
Screen diameter
material
Original Q/s
Screen
Screen length
material
Q/s before
Q/s after
Filter pack
action
action @
description
(@ what gpm)
Activity
Action description
Time interval
Dimensions
Notes/comments:
Sheet _1_ of ___
Signature and date (print name and title):
Plate D-10
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