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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> Address: —11.5, 1 M WeIIID: Date: <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: Ye1s: A /N1o: <br /> Location:(Latitude and Longitude-GPS): �7 ,A O 7 "A I p� + (1! x,35 a <br /> Remarks: <br /> Well Pad: YY <br /> Integrity: Good: Inadequate: '\ <br /> Presence of depressions or standing water around well: Yes: No: <br /> Remarks: . r ` j <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: �TTT <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: <br /> Signed Date <br /> • <br />