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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />ddress: <br />Elate: <br />Site Conditions/Access: <br />Accessibility: Good: 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: <br />No: <br />(Latitude and Longitude -GPS):17' <br />5-3 "S 7 'Al <br />Ir <br />Remarks: <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: V. - <br />Remarks: <br />Protective Outer Casing: Material: Vil L <br />Condition of Protective Casing: Good: <br />04-mmalted: <br />Condition of Locking Cap: Good: <br />Damaged: <br />0 4-L <br />Condition of Lock: Good: <br />JDamaged: <br />Condition of Weepholes; Good: <br />Damaged: <br />Remarks: <br />ell Riser: Material: Q ri <br />Condition of Riser: Good: <br />Damaged: <br />Condition of Riser Cap: Good: <br />0; -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 />