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9 <br />DOMESTIC/MUNICIPAL INSPECTION <br />Address: ell ID: <br />Date: -604 <br />Site Conditions/Access: <br />Accessibility: Good: Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />Yes: No: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Location: (Latitude and Longitude - GPS): 1 3 T. 1 <br />Remarks: <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes; _ No: <br />Remarks: <br />Protective Outer Casing: Material: <br />Condition of Protective Casing: Good: <br />Damaged: <br />Condition of Locking Cap:W � Good: <br />Damaged: <br />Condition of Lock: WI&Good: <br />Damaged: <br />Condition of eepholes:oj�\ 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 (H:): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />Date <br />