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E <br />DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />ddress-. as 61� jVeLJCd41I ID: <br />Date: L17n <br />ilte 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 />37 * 5 3TT Al <br />lc�- a V k/ <br />Remarks: <br />Well Pad: <br />Integrity: Good: x <br />Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: <br />Protective Outer Casing- Material: <br />AM +-r,- <br />Condition of Protective Casing: <br />Good: <br />0\'C -.Damaged: <br />Condition of Locking Cap: <br />Good: <br />Oyt-Damaged: <br />Condition of Lock: <br />Good; <br />0\4amaged.- <br />Good: <br />0\�ramaged: <br />Condition of Weepholes: <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 (Spm): <br />Current (Hz): <br />(check If electrical <br />problems suspected) <br />Remarks: <br />J <br />Field Certification: <br />