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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: Si -A " W IIID:' <br />Date: ! <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: No: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Longitude GPS): <br />'I 1,01 <br />Location: (Latitude and - <br />,b <br />Remarks: <br />Wel! Pad: <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Remarks: <br />Protective Outer Casing: Material: <br />e <br />Condition of Protective Casing: <br />Good: 0 'F` <br />Damaged: <br />Condition of Locking Cap: <br />Good: -c <br />Damaged: <br />Condition of Lock: <br />Good: 1K <br />Damaged: <br />Condition of Weepholes: <br />Good: b.6 <br />Damaged: <br />Remarks: <br />Well Riser: Material: <br />Condition of Riser: <br />Good: *%4- <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): (check if electrical <br />problems suspected) <br />Remarks: <br />WM- <br />I*--Signed <br />Date <br />