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. DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />J <br />0 <br />Address: Sl Z4, 6%.A-Nn4. RAWell ID: <br />Date: <br />U17-01 i -I <br />Site Conditions/Access: <br />/ <br />Accessibility: Good: ✓ Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />Yes: <br />No: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): — k 1 % . 24S <br />A-1'1 '3 <br />Remarks: Vil�c� c�r1 o d ( 11'1 c <br />A�"► a r1 v �c� rl i ��( C <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: f <br />Remarks: <br />Protective Outer Casing: Material: <br />Condition of Protective Casing: Good: �_ <br />Damaged: <br />Condition of Locking Cap: Good: tit A <br />Damaged: <br />Condition of Lock: Good: f4 A <br />Damaged: <br />Condition of Weepholes: Good: <br />Damaged: <br />Remarks: <br />Well Riser: 4..A 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 />Dedicated Pump: 1,4k\ Type: <br />Condition: Good: Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />Signed <br />