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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />C, <br />Field Certification: —� 1 gy p _ 4# Lzl / J7 <br />Signed Date <br />Address: _'4' 48-- 1.A -`f'1 Well ID: <br />Date: 4412. <br />Site Conditions/Access: <br />Accessibility: Good: .rj <br />Fair: <br />Poor: <br />Vicinity of well 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): <br />-J.," j ,�iL3�''ilac3 . - It ZZ C., � 1 <br />Remarks: S"`+�t�1 c � rum <br />S7i cjc�- c'.1 <br />t V-. Ci <br />%rn <br />Well Pad: <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Remarks: <br />Protective Outer Casing: Material: <br />Condition of Protective Casing: <br />Good: <br />Damaged: <br />Condition of Locking Cap: <br />Good: �L_ <br />Damaged: <br />Condition of Lock: <br />Good: <br />Damaged: <br />Condition of Weepholes: <br />Good: <br />Damaged: <br />Remarks: <br />Well Riser: iwiiN Material: <br />Condition of Riser: <br />Good: <br />Damaged: <br />Condition of Riser Cap: <br />Good: <br />Damaged: _ <br />Measurment reference point: <br />Yes: <br />No: <br />Remarks: <br />Dedicated Pump: Type: <br />Condition: Good: <br />Damaged: <br />Missing: _ <br />Pumping Rate (gpm): <br />Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: V YJ 4tytp�"� <br />Field Certification: —� 1 gy p _ 4# Lzl / J7 <br />Signed Date <br />