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L <br /> DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> � 001"' <br /> Address: loxia., Well 10: Date: <br /> Site Conditions/Access: <br /> Accessibility: Good: Fair: Poor: <br /> Vicinity of well clear of weeds and/or debris(Take Photo): Yes: No: <br /> Presence of depressions or standing water around well: Yes: No: <br /> Location:(Latitude and Longitude-GPS): 37 514 1 @S'I.A/ (ea I O M f_*+p LA f <br /> Remarks: L�� <br /> Well Pad: <br /> Integrity: Good: Inadequate: <br /> Presence of depressions or standing water around well: Yes: No: <br /> Remarks: <br /> 12 U if nYANL agoo.,J moi-' L*11Q d Mct kr� <br /> Protective Outer Casing: Material: j)VL <br /> Condition of Protective Casing: Good::_ Damaged: <br /> Condition of Locking Cap: Good: -X1— Damaged: <br /> . Condition of Lock: Good: Damaged: <br /> Condition of Weepholes: Good: Damaged: <br /> Remarks: <br /> Well Riser: Material: <br /> Condition of Riser: Good: �. Damaged: <br /> Condition of Riser Cap: Good: x Damaged: <br /> Measurment reference point: Yes: No: <br /> Remarks: <br /> Dedicated Pump: Type: <br /> Condition: Good: Damaged: Missing: <br /> Pumping Rate(gpm): Current(Hz): (check if electrical <br /> problems suspected) <br /> Remarks: <br /> Field Certification: <br /> Zoo 114?— <br /> Signed Dat <br /> • <br />