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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />• <br />• <br />Address: 2>szo SUf-In 2LX14ellID: <br />Date: <br />Site Conditions/Access: <br />Accessibility: Good: ✓ Fair: <br />Poor: <br />Vicinity of wetl2lear of weeds and/or debris (Take Photo): <br />Yes: No: <br />ls� <br />Presence of depressions or standing water around wNf' <br />Yes: No: <br />Location: (Latitude and Longitude - GPS): 3-1 •99 69 <br />+1 } — 12-1. • Z 1 ei S B4 <br />5G•�� (C -CA ICcCk+tan <br />Remarks: L <br />h sc. G �ddre5S f'h <br />Is ckri o - mob' 1z <br />V-% V-fML. c11 �g <br />Well Pad: N A <br />u n aC-Ge s5j b1 <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: No: <br />Remarks: <br />Protective Outer Casing: t-,jA 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: N4 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: Nt\ Type: <br />Condition: Good: Damaged: <br />Missing: <br />Pumping Rate (gpm): Current (Hz): (check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />