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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> g.l " I14 W-Cf Address: 02 -751 t,eWellID: Date: &h 7 <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): 37 •SY to'f *At 1a! <br /> Remarks: tJ6 <br /> Well Pad: <br /> Integrity: Good: Inadequate: <br /> Presence of depressions or standing water around well: Yes: No: K— <br /> Remarks: <br /> Protective Outer Casing: Material: J>k f�. <br /> Condition of Protective Casing: Good: _ Damaged: <br /> Condition of Locking Cap: Good: _ Damaged: �s <br /> • Condition of Lock: Good: _ Damaged: <br /> Condition of Weepholes: Good: N— Damaged: <br /> Remarks: <br /> Well Riser: Material: <br /> Condition of Riser: Good: C1 Damaged: <br /> Condition of Riser Cap: Good: CK 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: P Ali— <br /> Signed Date <br />