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Ah <br />D! ''+ !I SHEET <br />Address: 0 5u," 4 <br />u, `4 ell ID: <br />Date: tis L L ( 7 <br />Site Conditions/Access: <br />Accessibility: Good: ✓ <br />Fair: <br />Poor: <br />Vicinity of well clear of weeds and/or debris <br />(Take Photo): <br />Yes: No: <br />Presence of depressions or standing water <br />around well: <br />Yes: No: <br />Location: (Latitude and Longitude - GPS): <br />✓��], t: <br />®�1 [� C <br />Remarks: W f,�[ 11® fi <br />�j <br />ck��, <br />Well Pad: <br />` <br />Integrity: Good: <br />Inadequate: <br />Presence of depressions or standing water <br />around well: <br />Yes: No: <br />Remarks: <br />Protective Outer Casing, Material: <br />baee B <br />Condition of Protective Casing: <br />Good: <br />Damaged: <br />Condition of Locking Cap: <br />Good: <br />Damaged: <br />Condition of Lock: <br />Good: _� <br />Damaged: <br />Condition of Weepholes: <br />Good: <br />Damaged: <br />Remarks: <br />Well Riser: Material: <br />"t <br />C,AA-Ar <br />Condition of Riser: <br />Good: <br />Damaged: <br />Condition of Riser Cap: <br />Good: <br />Damaged: <br />Measurment reference point: <br />Yes: <br />No: <br />Remarks: <br />Dedicated Pump: Type: <br />Condition: Good: <br />Damaged: <br />Missing: <br />Pumping Rate (gpm): <br />Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: t/L7 <br />Field Certification: <br />Signed <br />Date <br />