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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />0 <br />s>, Y -In <br />Address: 3 05%-p Well ID: <br />Date:. ZG' <br />11 <br />Site Conditions/Access: <br />Accessibility: Good: Fair: <br />Poor: <br />tin CX5e- <br />✓ <br />Vicinity of wet tlear of weeds and/or debris (Take Photo): <br />Yes: <br />No: <br />NG Pin CA O <br />Presence of depressions or standing water around we . <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): - i 2� • Z 1`102 <br />* 3'�1 . <br />69 9 4-+ 1 <br />Remarks: <br />Well Pad: �,; ,n Vy., C Wn <br />Integrity: Good: 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: Good: <br />Damaged: <br />Condition of Locking Cap: Good: <br />Damaged: <br />Condition of Lock: Good: <br />Damaged: <br />Condition of Weepholes: Good: <br />Damaged: <br />Remarks: U h V-" ok,_>n <br />Well Riser: Material: <br />Condition of Riser: Good: <br />Damaged: <br />Condition of Riser Cap: Good: <br />Damaged: <br />Measurment reference point: Yes: <br />No: <br />Remarks: <br />h <br />Dedicated Pump: Type: <br />Condition: Good: Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: V 1 vrl d W n <br />Field Certification: .�-Y,d(zlo..41-gy 4/ 2-011 1 <br />Signed Date <br />