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G. <br />0 DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />A?M <br />�Well�ID:� <br />Date: <br />Fddr�ess:-Jb <br />Site Condftlons/Access- <br />Accetsiblilty; Good: Fair: <br />Poor; <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />70 T <br />Yes: <br />No: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GF 7" ): <br />44 1 <br />Remarks: <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 Weephoies: 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: TYPI <br />Condition: Good: n Damaged, <br />Missing: <br />A-4 <br />Pumping Rate (gpm): Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />%do I I ft A --- I <br />A 6 n f F, s I <br />W! <br />