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0 <br />DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />0 <br />ddress: t1- Wel <br />Date: <br />Site Conditions/Access: <br />Accessibility- Good: <br />Fair: Poor: <br />Vicinity of well clear of weeds and/or debris (Take <br />Yes: <br />No: <br />Presence of depressions or standing water aroLmd well: <br />Yes: <br />No: <br />Location: Longitude GPS): <br />�� <br />a <br />34/1,j l 1 <br />(Latitude and - <br />Remarks: <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 />V <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: <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 />0 , - <br />�10 <br />Date <br />I <br />