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61 <br />ell ID: Date: VI J /.4; 1 <br />ons/Access: <br />Accessibility: Good: Fair: Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): Yes: No: <br />Presence of depressions or standing water around well: Yes: No: <br />!�1�/\/—E sr <br />Location: (Latitude and Longitude - GPS): <br />Remarks: U — _ -- _ _ — r -,A ., k- c- <br />Pad: ' <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: Yes: No: <br />Remarks: <br />Outer Casing: Material: <br />Condition of Protective Casing: Good: Damaged: <br />Condition of Locking Cap: Good: Damaged: <br />Condition of Lock: Good: Damaged: <br />Condition of Weepholes: Good: Damaged: <br />Remarks: <br />Well Riser: Material: V1,di 1 <br />Condition of Riser: Good: Damaged: <br />Condition of Riser Cap: Gobd: Damaged: <br />Measurment reference point: Yes: No: <br />Remarks: <br />Pump: Type: <br />Condition: Good: <br />Pumping Rate (gpm): <br />Remarks: <br />Field Certification: 1 <br />Signed <br />Damaged: Missing: <br />Current (Hz): (check if electrical <br />problems suspected) <br />En <br />