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WELLHE INSPECTION CHECKLIST AND FAIR ORDER <br /> Client 4t <br /> Inspection ❑ate--- ��'�U� <br /> Site Address zj�f0 _ �• � l" l.,l.� 1 toe Inspected By� rN <br /> Od—un box? 6 Casing secure? 12. Water standing in weltbox? 15 Well cap Functional? <br /> Z Lld broken? 7 Casing cut level? 12a.Standing above the top of casing7 16 Can cap be pulled loose? <br /> 3.Lid Wits missing? 8 Debris In welibox? 12b Standing below the top of casing? 17.Can cap seal out water? <br /> 4 Lid boas stepped? 9 Well box Is too far above grade? 12c.Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal Intact? 10 Weilbox Is too far below grade? 13 Well cap present? 18 Padlock functional? <br /> 11 We[lhox Is crushed/damaged? 14 Well cap found secure? <br /> Check box if no deficiencies were found Note below deficienciesY ou were able to correct. <br /> Well I.D Deficiency Corrective Action Taken <br /> I <br /> Note below all deflencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Con-ection to: assigned corrected <br />