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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> Address: 7A f Well ID: Date: o� <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: )) q No: <br /> Location:(Latitude and Longitude-GPS): 3� '59 /a I `101 a Of 0-2 I/�'✓ <br /> Remarks: <br /> Well Pad: (A50 `tot S IV- <br /> Integrity: Good: Inadequate: <br /> Presence of depressions or standing water around well: Yes: No: <br /> Remarks: ��r✓1 <br /> nl ouasik <br /> If <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: `Y, <br /> q E- J� j C\ V e d;a�' �- wc�� �rF►e o h9 o <br /> Well Riser: JV t Material: � a I n i —e <br /> Condition of Riser: Good: _ Damaged: <br /> Condition of Riser Cap: Good: _r> 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: J" <br /> Signed Date <br /> • <br />