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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET ' <br /> Q l+ O pp <br /> Address: ' 19a Wel ID: Date: b l� <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 /> , 1 <br /> Location:(Latitude and Longitude-GPS): 7o y/� / , eo!V r 1® 169 � k./ <br /> Remarks: <br /> Well Pad: <br /> IntegritCofdepres;sIs <br /> ds Inadequate: <br /> Presen or standing water around well: Yes: No: <br /> Remarks: <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: 2S, 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: 4z1911f2 <br /> Signea Date <br />