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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />Address: 3'7n a S�jnv% Well ID: <br />Date; <br />Site Conditions/Access: <br />/ <br />Accessibility: Good: / Fair: <br />Poor: <br />aae o♦ <br />1Fi�+it i --i clear of weeds and/or debris (Take Photo): <br />Yes: _�� No: _ <br />Presence of depressions or standing water around well: <br />Yes: No; ✓ <br />Location: (Latitude and Longitude - GPS): -^ 12 ( 2-1-L fl^C , :5-1 . SQL?>Ck—y1 <br />CIO%V%"lvAA% rfc.\\ wu.s�c�► ono} n.t1.-�.� E'er•— sG.v.',P1��� SJ <br />Remarks: <br />Well Pad: <br />Integrity: Good: ✓ Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: �_ No: <br />Remarks: <br />�'-�r*1 lG �'� b-� G011Gc�}Gc�1 �rprY� WG1i 11e1J►C�• <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 />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 />Signed <br />Date <br />