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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: 4tLQL1=—,ell ID: <br />Site Conditions/Access: <br />Accessibility., Good: <br />Fair: <br />Poon. <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />Yes: <br />No: <br />Presence of depressions or standing water <br />around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS); <br />Remarks: <br />ell Pad: N't <br />Integrity: Good- <br />Inadequate: <br />Presence of depressions or standing water <br />around well: <br />Yes: <br />No: <br />Remarks: <br />Outer Casing: Mater1al:K-D("-\ <br />IFA)O-A <br />r��tdltlon <br />slt <br />of Protective Casing: <br />Good: f.,!h <br />Damaged: <br />"I <br />Condition of Locking Cap: <br />Good: <br />Damaged: <br />Condition of Lock: NiM <br />Good: <br />Damaged: <br />Condition of Weepholes: <br />Good: <br />Damaged: <br />Remarks: <br />Well Riser: Material: <br />\TGood: <br />N't <br />Condition of Riser: <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 (gpm): <br />Current (Hz): <br />(check If electrical <br />problems suspected) <br />Remarks: <br />A n <br />% <br />Field Certification: <br />