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0 DOMESTIC/MUNICIPAL WELL INSPECTION <br />C <br />:7 <br />Address: Kotl!5r-LIIID: <br />Date: AAWt <br />-7 <br />Site Conditions/Access: <br />Accessibility: Good: <br />Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />Yes: <br />No: <br />Presence of depressions or standing water <br />around well:: <br />Longitude GPS): <br />LYes: <br />54'-V <br />pNo: <br />t oA/p r p ®( t ! <br />Location: (Latitude and - <br />/ <br />Remarks: <br />Well Pad, <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: <br />Protective Outer Casing: Material; <br />_Ay <br />Condition of Protective Casing: <br />Good: <br />Damaged: <br />Condition of Locking Cap: <br />Good: <br />Damaged: <br />Condition of Lock: <br />Good: <br />Damaged: <br />Condition of Weepholes: <br />Good: 31 <br />Damaged: <br />Remarks: <br />Well Riser: Material: <br />Condition of Riser: <br />Good: <br />Damaged: <br />Condition of Riser Cap: <br />Good: <br />Damaged: <br />Measurment reference point: <br />Yes: <br />No: <br />Remarks: <br />Dedicated Pump: Type: <br />Condition: Good: <br />Damaged: <br />Missing: <br />Pumping Rate (gpm): <br />Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />Signed <br />Date <br />