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0 <br />DOMESTIC/MUNICIPAL INSPECTION <br />E <br />Address: ' 2 S�Ytr'ta� Well ID: <br />Date: <br />l0 �2O <br />yi <br />Site Conditions/Access: <br />Accessibility: Good: ✓ Fair: <br />Poor: <br />hc;,ej spieic:,k <br />Vicinity of clear of weeds and/or debris (Take Photo): <br />Yes: <br />No: <br />.S?tgat <br />Presence of depressions or standing water around Well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude • GPS): <br />Remarks: <br />Well Pad: A (in `flG f <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: <br />Protective Outer Casing: r lA 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: <br />Well Riser: {`S %t 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: 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: f + l <br />Signed Date <br />