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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />0 <br />Address: 39 3S y d Well ID: Date: <br />Site Conditions/Access: <br />Accessibility: Good: ✓ Fair. _ Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): Yes: <br />No: <br />Presence of depressions or standing water around well: Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): <br />( Cp-5 5► wed V -Y <br />Remarks: <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around ell: Yes: <br />No: <br />Remarks: um •k& 4Q ( - (.0 06 {- AO -e-,5 s <br />Protective Outer Casing: Material: <br />Condition of Protective Casing: Good: _ <br />Damaged: <br />Condition of Locking Cap: Good: <br />Damaged: <br />Condition of Lock: Good: <br />Damaged: <br />Condition of Weepholes: Good: <br />Damaged: <br />Remarks: <br />Well Riser: Material: <br />Condition of Riser: Good: <br />Damaged: <br />Condition of Riser Cap: Good: <br />Damaged: <br />_. <br />Measurment reference point: Yes: <br />No: <br />Remarks: <br />Dedicated Pump: Type:_ <br />Condition: Good: Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />2Z// 7 <br />Date <br />