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WELLH:_ INSPECTION CHECKLIST AND i,,EPAIR ORDER <br /> r .t <br /> Client -She// _ Inspection Date 3 0 <br /> Site Address_ I P& 7 Crot," —� 16 c l � Inspected By <br /> 1.Lid on box? B. Casing secure? 12. Water standing In welibox? 15.Wee cap functional? <br /> 2.Lid broken? 7. casing cut level? 12a.Standing above the top of casing? 16.Can cap be pulled Inose? <br /> a. Lid bolts missing? a. Debris 1n wellbox? 12b.Standing below the top of casing? <br /> V.Can cap seal out water? <br /> 4.Ud baits stripped? 9. Wallbox is.too far above grade? 12c.Water even with the top of casing? 18.Padlock present? <br /> S.Lid seal intact? 10.Wallbox Is too far below grade? 13. We -m present? :19.:> adlock1uncEhmel? — <br /> 11.Wallbox Is crushed/damaged? 114. 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 MI defiencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br />