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• DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br />Address: �Vjlell ID: <br />Date: -7 <br />Site Conditions/Access: <br />Accessibility: Good: Fair.y <br />Poor: <br />Vicinity of well clear of weeds and/or debris (Take Photo): <br />Yes: <br />No: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Location: (Latitude and Longitude - GPS): <br />�,ie toaed Si^C 6a IPA�jpl <br />{{ 1 <br />f}{C� IJn ` 1,L-� - <br />Remarks: <br />Vy <br />W ( u <br />Well Pad: <br />Integrity: Good: Inadequate: <br />Presence of depressions or standing water around well: <br />Yes: <br />No: <br />Remarks: N a acte5-6 <br />Protective Outer Casing: 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: Vii) 0�-L CCi27 v -,CO <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: <br />Remarks: too P\C <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: (�U t 5� +V Wfjl <br />Field Certification: <br />Signed <br />0 <br />Date <br />1/IAt.L� C <br />