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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client AF: %;vo, - - Inspection Date 1 -14-01 <br /> Site Address__ 6..0 U, G L *r fcr Uy, .I h e*t 9%- Inspected <br /> 1.Lid on box? 6. Casing secure? 12. Water standing in wellbox? 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 seal out water? <br /> 4.Lid bolts stripped? 9. Wellbox is too far above grade? 12c.Water even with the top of casing? 18.Padiock present? _ <br /> — 5,Cid'seaI�intact? 10.Wellbox is too far below grade? 13. Well cap present? 19.Padlock functional? <br /> 11.Wellbox is crushedtdamaged? 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. Deficien2y Corrective Action Taken <br /> r+4ief-fl� <br /> rep <br /> >D ACV <br /> t S -%z, for <br /> AdP <br /> Note below all deflencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> i <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> a <br /> Ji <br /> 6 q <br /> a <br /> !IV- ( Aal I fs" it It, <br /> 'yS <br />