Laserfiche WebLink
DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> ^ gnat rOf r <br /> Address: I Cell ID: Date: <br /> Site Conditions/Access: <br /> Accessibility: Good: Fair: Poor: <br /> Vicinity of well clear of weeds and/or debris(Take Photo): Yes: No: <br /> Presence of depressions or standing water around well: Yes: No: <br /> • ! h • / iv <br /> Location:(Latitude and Longitude-GPS): -0 ( A l t <br /> Remarks: <br /> Well Pad; <br /> Integrity: Good: Inadequate: <br /> Presence of depressions or standing water around well: Yes: No: <br /> Remarks: <br /> Protective Outer Casing: Material: Q ka , <br /> Condition of Protective Casing: Good: Damaged: <br /> Condition of Locking Cap: Good: Damaged: <br /> Condition of Lock: Good: Damaged: <br /> Condition of Weepholes: Good: Damaged: <br /> Remarks: <br /> Well Riser: Material: eAgm k <br /> Condition of Riser: Good: . Damaged: <br /> Condition of Riser Cap: Good: Damaged: <br /> Measurment reference point: Yes: No: <br /> Remarks: <br /> Dedicated Pump: Type: <br /> Condition: Good: Damaged: Missing: <br /> Pumping Rate(gpm): Current(Hz): (check if electrical <br /> problems suspected) <br /> Remarks: <br /> Field Certification: it 2 <br /> Signed Date <br />