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0 <br />DOMESTIC/MUNICIPAL INSPECTION <br />n <br />C7 <br />Field Certification: <br />Signed <br />Date <br />Date: <br />Address:( e11 iD: <br />_ <br />Site Conditions/Access: <br />Accessibility: Good: <br />Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris <br />(Take Photo): <br />Yes: <br />No: <br />Yes: <br />No: <br />Presenc of depressiQ01s or standing water <br />around well: <br />Location:itude and Longitude - GPS): <br />Remarks: <br />Well Pad: <br />Integrity: : _ <br />Inadequate: <br />Present f depres s or standing water around well: <br />Yes: �l� <br />No: <br />Remarks: <br />Protective Outer Casing: Material: <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: <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 />