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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: 415Z Ar-Qh Ckj Well ID: <br />Date: <br />Site Conditions/Access: <br />Accessibility: Good: J Fair: <br />Poor: <br />Irti�`,�c' <br />Vicinity ofAw ltc ear of weeds and/or debris (Take Photo): <br />Yes: ✓� <br />No: <br />Presence of depressions or standing water aroundi ` <br />Yes: yr_ <br />No: <br />Location: (Latitude and Longitude - GPS): 3,7 ,cam{ c4. <br />R42 , — 121 , 7-6A <br />'I 12 <br />Remarks: W e%\ 1 n <br />yx <br />Well Pad: NA <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: <br />Protective Outer Casing: NA 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: NA 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: NA Type: <br />Condition: Good: Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: z2�2 <br />0 <br />qje <br />