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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />0 <br />NtwCxk1%1 C <br />Address: -1 4-85 Q-04MCI Well ID: <br />Date: IQ � 17 <br />Site Conditions/Access: <br />Accessibility: Good: <br />Fair: <br />Poor: <br />-vl csa <br />Vicinity ofytelFclear of weeds and/or debris <br />(Take Photo): <br />Yes: No: <br />Presence of depressions or standing water around <br />Yes: No: v� <br />Location: (Latitude and Longitude - GPS): <br />3`1 : Bei 7, — Z (. 24C2 1O to IPS <br />6V.a1r�CY' <br />Remarks: "'�' -�` S <br />USr_ "c -s-- t n <br />Fr,� ,—% } 43P hcy-Ne— , <br />�► � C��'1 <br />iGF'-�- oE'- w c.� 1 k-t,.� a 10��o r't •ter-► � ry <br />Well Pad: l)`1 K-✓rU'� <br />4t� �ro.� <br />coo r p c� <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Remarks: <br />Protective Outer Casing: Maferial: <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 />U;, kr�lawr� <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 />V h VK-0l:Jh <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: L) kh OC. <br />AQ <br />Field Certification: <br />Date <br />