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DOMESTIC/MUNICIPAL WELL INSPECTION SHEET <br /> Address: 22 S - Well ID: Date: <br /> Site Conditions/Access: <br /> Accessibility: Good: fair: z� 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 /> ^ <br /> Location:(Latitude and Longitude-GPS): 37 59 '-)l 1 <br /> / *68 6 <br /> Remarks: <br /> N Q <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: 11Pr La i <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: <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):µ (check if electrical <br /> problems suspected) <br /> Remarks: <br /> Field Certification: s,/" <br /> ( <br /> Signed Date <br /> 10 <br />