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WELLH1=hLj INSPECTION CHECKLIST AND REPAIR ORDER <br /> Cllent �// Inspection Date <br /> e Address U/Z Inspected By <br /> 1 Lid on box? 6 Casing secure? 12. Water standing In wellbox? 15,Well cap functional? <br /> 2 i_id broken? 7 Casing cut level? 12a.Standing above the top of casing? 16.Can cap be pulled loose? <br /> 3 Lid bolts missing? B. Debris In wellbox? 12b.Standing below the top of casing? 17.Can cap seal cut water? <br /> 4 Lid bolts stripped? 9. Weilbox Is too far above grade? 12c.Water even with the top of casing? 18.Padlock present? <br /> 5. Ltd seat Intact? 10 Wellbox Is too for below grade? 13. Wall cap present? 19 Padlock fanclional? <br /> III Wellbox is crushedldamaged7 114 Well cap found secure? <br /> Check box if no deficiencies were found. Nota~ below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> I <br /> Nate 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 Deflciency defers Corredon to: assigned corrected <br />