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WELLHEAD INSPECTION CHECKLIST AND RENAIR ORDER <br /> -tient Inspection Date _ Z <br /> Site Address - ��'�'' Inspected 6y <br /> I.Lid on box? 6 Casing secure? 12 Water standing in wellbox7 15 Well cap functional? <br /> >_ Lid broken? 7 Casing nut level? 12a Standing above the top of casing? 113 Can cap be pulled Nose? <br /> I Lid bolts missing? 8 Debris In wellbox? 12b.Standing below the top of casing? 17 Can cap seal out water? <br /> 1.Lid bolls stripped? 9 Wellbox Is too for above grade? 12c Water even with the top of casing? 18 padlock present? <br /> �.Lid seal Intact? 10 Wellbox Is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11.Wallbox is crushed/damaged? 14 Well cap found secure? <br /> nm'-Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> Nell I.D. Deficiency Corrective Action Taken <br /> We below all defiencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Veli I.D. Persisting Deficiency defers Correction to: assigned corrected <br />