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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: Well ID: <br />Date: LIZ�t� <br />Site Conditions/Access: <br />Accessibility: Good: '� <br />Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris <br />(Take Photo): <br />Yes: No: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Location: (Latitude and Longitude - GPS): <br />�� • 9o�O17 tJ� — ('z,� (q �� 55 <br />s <br />Remarks: SAv~1 1c, mtk>CS <br />L -C, -ktt,- <br />ew r.... (Ca to is b i✓�. <br />Well Pad: WO 10 4:4 <br />y <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 />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: Pro <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 />T2ug �J <br />�. <br />Field Certification: <br />0 <br />Date <br />