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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: ell ID: <br />Date: 4t I ZZ 13 <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: <br />No: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): <br />'3'l . 8'�\ R3Z, _ — m %, 202.2"l % <br />t>wM1cr ^614CA i-hq} w e <br />Remarks: "O%le <br />m,p(e <br />�y, WN <br />Ft-O►'1 E t^c� �V t <br />G1' F�ncaY1 <br />LJT�\ Ctrl 10r <br />Well Pad: <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water 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: <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: V i1 �n GwY1 <br />Dedicated Pump: Type: <br />Condition: Good: <br />Damaged: <br />Missing: <br />Pumping Rate (gpm): <br />Current (Hz): <br />T <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: _ / WZ 7- 11'1 <br />Signed Date <br />