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0 <br />DOMESTIC/MUNICIPAL WELL INSPECTION <br />Address: Ul Q ell ID: t Date, _ I <br />Site Conditions/Access: <br />Accessibility: Good: Fair: Poor: <br />weeds debris Photo): <br />Yes: <br />No: <br />clear of and/or (Take <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): — 17— .III SSQ , 3 j • 281 <br />Remarks: CCPD c, <br />�Li <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: <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 />0 <br />