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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />Field Certification: <br />Address: •'131'1 Well ID: <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: v, <br />No: <br />J <br />Presence of depressions or standing water <br />around well: <br />Yes: <br />No: +� <br />Location: (Latitude and Longitude - GPS): <br />3" i • 99 C.VLO ZZ , — l V • Zo"L "} •3-1 <br />Remarks: G`%A V1 <br />1.t ,Nk to <br />{ C<--k.-I V-01 tS+t"UC—+v "G <br />I <br />t-► <br />Well Pad: <br />f <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water <br />around well: <br />Yes: <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: t,,1*A <br />Damaged: <br />Condition of Lock: <br />Good: <br />Damaged: <br />Condition of Weepholes: <br />Good: <br />Damaged: <br />Remarks: <br />Well Riser: h.1 A 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: KA 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 />