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• <br />DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />Address: n" ' Well IV <br />Date: b .? / <br />Site Conditions/Access: <br />Poor. <br />Accessibility: Good: fa <br />Vicinity of well clear of weeds an or i�ebrl Photo): <br />Yes:_ <br />No: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />• <br />Location: (Latitude and Longitude - GPS): � % � <br />l •1. 0. <br />4 l .4 I a 1 ' <br />! i l <br />(16_ <br />Remarks: 5 �� }� 1� �1� 16 v 4�i Li1.1(� �• <br />/ -f-j' r,.e <br />Well Pad: <br />Integrity: Good:t� Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: <br />Protective Outer Casing: Material: �- <br />Condition of Protective Casing: Good: _ �' <br />Damaged: <br />Condition of Locking Cap: Good:_ <br />Damaged: <br />Condition of Lock: Good: <br />Damaged: <br />Condition of Weepholes: Good: <br />Damaged: <br />Remarks: <br />Well Riser. Material: <br />Condition of Riser: Good:_ <br />Damaged: <br />Condition of Riser Cap: Good:_ <br />Damaged: <br />Measurment reference point: Yes: <br />No: <br />Remarks: <br />Dedicated Pump: Type: <br />Condition: Good: Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />0 <br />Signed Date <br />