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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: 3440 'S1-.nny QC <V1 Well ID: <br />Date: �c�� Z1 � n <br />Site Conditions/Access: <br />Accessibility: Good: ✓ <br />Fair: <br />Poor: <br />*1r% -el C>1 <br />vicinity otmIll clear of weeds and/or debris <br />(Take Photo): <br />Yes: No: <br />Presence of depressions or standing water <br />around <br />Yes: No: <br />Location: (Latitude and Longitude - GPS): <br />'31 901"1 G t' -s <br />- I, Z1 7-t IES C --t c�3 <br />Remarks: "6t FQ�- *vie I— tr1 <br />+'Ke bcst <br />4aty Ic- MIC,} exCC_P_SS 161 <br />Well Pad: V.JA 'gip t c1.c:,} ih <br />Integrity: Good: <br />Inadequate: <br />� i c:,tvv <br />Presence of depressions or standing water <br />around well: <br />Yes: %p t cjc{ 401 b ckc <br />y �w vin Q 4� �X=tS <br />Remarks: <br />Protective Outer Casing: W/k Material: <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: 1SA Material: <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: t.�A Type: <br />Condition: Good: <br />Damaged: <br />Missing: <br />Pumping Rate (gpm): <br />Current (Hz): <br />(check if electrical <br />problems suspected) <br />Remarks: <br />Field Certification: <br />0 <br />