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WELLHLko INSPECTION CHECKLIST AND RF-PAIR ORDER <br /> Client <br /> Inspection Date <br /> Site Address Gou L`.). ear` r-le Inspected By • R3 eSs <br /> 1 Lid on box? 5 Casing secure? 12. Water standing in weiibox? IS Well cap fun ftai? <br /> 2 Lid broken? T. Casing cut Ievel? 120 Standing above the top of casing? 18.Can cap be purled loose? <br /> 3.Ud bolts missing? 8 Debris In wellbox? 12b Standing below the tap 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 Padlock present? <br /> 5 Ud seal Intact? 10 Wellbox Is too far below grade? 13 Well cap present? 19 Padlacic funclinna!? <br /> 11.WeI16r Is crushed/demaged? 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. Deficiency Corrective Action Taken <br /> i <br /> Note below all defiencies that could not be corrected and stili need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persistln Deficleng defers Correction to: assigned corrected <br />