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® DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> yQos� It f <br /> Address: ! t(a Well ID: Date: <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: No: <br /> location:(Latitude and Longitude-GPS): 7" S ( �"N al ®05+ (y <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: 6,11- <br /> ---x- <br /> Condition <br /> .tCCondition of Protective Casing: Good: // Damaged: <br /> Condition of Locking Cap: Good: *, Damaged: <br /> ® Condition of Lock: Good: >< Damaged: <br /> Condition of Weepholes: Good: x 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: 6 / i <br /> Signed Date 21 <br />