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0 <br />DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />n <br />C <br />Address: 6 701 > T Well ID: <br />Date: f, kan <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 around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): <br />^� <br />J i a 5qIy'd it e t ,Q <br />jV <br />c>t '� <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 />C. <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 />Date <br />