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• <br />r� <br />DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: D 35 ��►{t �"tw WjII ID: <br />Date: (I/--?/ <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 />iL <br />Presence of depressions or standing water <br />around well: <br />Yes: <br />No:! <br />Location: (Latitude and Longitude - GPS): <br />i 7'0 Sy <br />3 3 ifil/ /a/ <br />��� �� � <br />� 4,/ <br />Remarks: <br />Well Pad: <br />` ` <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water <br />around well: <br />Yes: <br />No: <br />t <br />Remarks: <br />Protective Outer Casing: Material: <br />ey C - <br />Condition of Protective Casing: <br />Good: <br />Damaged: <br />Condition of Locking Cap: <br />Good: <br />Damaged: <br />Condition of Lock: <br />Good: K <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: <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 />Field Certification: <br />Ma <br />Date <br />