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T <br /> WELLHE!--INSPECTION CHECKLIST-AND K--:,)AIR ORDER i <br /> r .tient � A1— .. <br /> Inspection bate Z �� <br /> Site Address�� d !d, ��csr Grf�. �C Inspected B, 4, <br /> 1. Lid on box? 6. Casing secure? 12. Water standing in well box? IS.Well Cap functional? <br /> 2. Lid broken? 7. Casing cut level? 12a. Standing above the top of casing? 16. Can cap be pulled logse7 <br /> 3. Ud bolts missing? 8 Debris in wellbox? 12b.Standing below the top of casing? 17. Can cap soal out water? <br /> 4. lid bolts stripped? 9. VVeilbox is too far above grade? 12c.Water even with the top of casing? 18. Padlock present? <br /> 5=Lid-seal intact? -10:Weltbvx is toa#ar-t7elow grade?= 13=Well°cap--presanl? 19Padlock"functional? <br /> 11. Wellbox is crushed/damaged? 14. Well cap found secum? <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 /> z 4m <br /> �q •. �, <br /> 1-07 <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 LD. Persistin _Deficiency defers Correction to: assigned corrected <br /> •'f it� Y' /e G J - <br />