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vv>^Li_tIL INSPECTION CHECKLIST AND I .'AIR ORDER <br /> Client Skd Inspection Date ctt0� $-t- <br /> Site Address Igo V iG+pr L.-O ok ; <br /> - � Inspected By <br /> 1 Lid on box? 6. Casing secure? 12 Water standing In wellbox? 15.Well cap functional? <br /> 2.Lid broken? 7. Casing cot 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 out water? <br /> 4.Lid bolts stripped? 9 Wellbox Is loci far above grade? 12a.Water even with the top of casing? 18.Padlock present? <br /> 5 Lid seal Intact? 10 Wellbox Is too far below grade? 13 Well cap present? 19.Padlock functional? <br /> 1 i Wellbox Is crushed/damaged? 114, Well cap found secure? <br /> 0 Check box If no deficiencies were found Note below deficiencies you were able to correct. <br /> Well LD. Daficlena Corrective Action Taken <br /> mw-,z ��►o lun. cr4. 14 1&-ce A Loc-k, <br /> �-tw-3 13rak -� Uoe-k- <br /> Note below all defiencles that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.O. Persisting Deficiency defers Correction to: assigned corrected <br />