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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />r^ WelIID: Date: <br />r <br />ddress: -- <br />Site Conditions/Access: v <br />X— Poor: <br />Accessibility: Good: Fair: <br />Vicinity of well clear weeds /or debris (Take Photo): Yes: <br />No: <br />Presence of depressions or standing water around well: Yes: <br />No: %C <br />a i <br />Location: (Latitude and Longitude • GPS): <br />Remarks: <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: Yes: <br />No: <br />Remarks: <br />10- Pot EC-0j <br />Protective Outer Casing: Material: 1 <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 />Signed <br />Date <br />