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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />0 <br />Address: )102- rT -Ck^' Well ID: <br />Date: <br />Site Conditions/Access: <br />Accessibility: Good: Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />Yes: No: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Location: (Latitude and Longitude - GPS): <br />.�.� <br />Remarks: (��,1rC '� �p.,+ o P r pt/ -Ey . tj �L�" 1...."— �L•aT)-C�t�l 5 <br />Well Pad: <br />Integrity: Good: Inadequate: <br />i✓ <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Remarks: <br />Protective Outer Casing: Material: M <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: to Il`, 10-{' ��,�-w num rCJ�� <br />o'�' E,N6 101 <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: r <br />Remarks: Gp1-4 Of tAiAC, <br />Dedicated Pump: Type: <br />Condition: Good: — Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): _ (check if electrical <br />Remarks: / a � VW -t' <br />problems suspected) <br />Field Certification: 1,,/,— <br />Signed <br />4/n/ <br />Date <br />