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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> ,�►�rr9 osa � <br /> Address: )13`d P Well ID: Date: ld? <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): ® 4 r H ®OV1701V <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; 1 <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: <br /> I 101 66y 624 VIL& tB <br /> Well Riser: Material: i <br /> Condition of Riser: Good: Damaged: <br /> Condition of Riser Cap: Good: Yo Damaged: <br /> Measurment reference point: Yes: No: <br /> Remarks: CA,�„ CA 4�� <br /> { --a r <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: <br /> Signed Daft <br />