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® DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> 6'r eo C <br /> Address: ��t� �► a Well ID: Date: /`-7 <br /> Site Conditions/Access: <br /> Accessibility: Good: X_ 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: d No: <br /> Location:(Latitude and Longitude-GPS): -' o Sy ' y I ® i , <br /> Remarks: <br /> Well Pad: <br /> Integrity: Good: Inadequate: <br /> Presence of depressions or standing water around well: Yes: No: <br /> Remarks: <br /> Protective Outer Casing: Material: 1 <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: ` f� <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 /> AT A <br /> Field Certification: SL <br /> Signe d Date <br />