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® DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> C3� � mo�r��®Sy <br /> Address: b We1110: 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): Ca f to <br /> marks: <br /> Well Pad: <br /> a <br /> Integrity: Good: Inadequate: <br /> Presence of depressions or standing water around well: Yes: No: <br /> Remarks: <br /> Protective Outer Casing: Material: <br /> Condition of Protective Casing: Good: Damaged: <br /> Condition of Locking Cap: Good: 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: 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 /> Signed a t, b f' f a d � h e Rate <br /> CL if Qi��nq �i a�lew►3 , LAv�� 1✓ w > )0('q <br /> )Vex E- LJO0r , 50 �' had Kf <br /> rex 4--~- <br />