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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client t'l Inspection Date j.11'0 <br /> (OSlte Address f4%% Inspected By re3 <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wetlbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seat out water? <br /> 4 Lid bolts stropped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secure? <br /> Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deli ienc defers Correction to assigned corrected <br /> U YMA 44111., LOW" <br /> n%r^J�- v+a f„r4tll.,r <br /> M v'7 . f i p t Q- <br /> 10 e.[- <br /> t - ► � 3 �< cam,., �.,�- }. F� <br /> i 1 1 <br />