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0 <br />TIC/ ICI WELL INSPECTION SHEET <br />lAddress: Mok('ell Ib: Date; <br />ofib/licumob. <br />Accessibility. Good: Fair: Poor; CLOW <br />Vicinity of well clear of weeds and/or debris (Take Photo) rw P,4 140- AQ No: Ll!? <br />Presence of depressions or standing water around well: Yes: — No. <br />location: (Latitude and Longitude - GPS): 17 A 9 Y I q I "AIJ I&I a I Q 20 <br />Remarks: <br />Well Pad: #I I I C/ <br />L <br />Integrity: N Inadequate: <br />Presence of depressions or standing water around well: Yes: No: <br />Remarks: <br />,otective Outer Casing: A)IA- Material: <br />Condition of Protective Casing: Good: Damaged: <br />ndition of Locking Cap: Good: Damaged: <br />Condition of Lock. Good: Damaged: <br />Condition of Weepholes: Good: Damaged: <br />Remarks: <br />Al Riser: Material: <br />Ob Cclition of Riser: Good: Damaged: <br />Condition of Riser Cap: Good: Damaged: <br />Measurment reference point: Yes: No: <br />Remarks: <br />Pump: Type: <br />Condition: Good: <br />Pumping Rate (gpm): <br />Remarks: - <br />Damaged: <br />Missing: <br />(check If electrical <br />problems suspected) <br />Field Certification: 'A'I <br />-- --7- �-' <br />Signe W Date <br />