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t t <br /> WELLHEtiD INSPECTION CHECKLIST AND R►-PAIR ORDER <br /> Client 6af„�4 i lrsn . <br /> Inspection Date Z,11he <br /> Site AddressJ Z6"7 Co�,��r. f jW�. �,1 f"JC�4," Inspected By . <br /> 1.Lid on box? 6. Casing secure? 12. Water standing In wellbox? 115.Wen cap functional? <br /> 2.Ltd broken? 7. Casing cut level? 12a.Standing above the top of casing? 16.Can cap be pulled loose? <br /> 3.Lid baits missing? B. Debris In wetlbox? 12b. Standing below the top of casing? 17.Can cap seal out water? <br /> 4. Lid bolts stripped? B. Weilbox Is too far above grade? 12c.Water even with the top of casing? 18.Padlock preserfl7 <br /> 5. Lid seal Intact? 10.Wellbox Is ton far below grade? 13. Wet[cap emsent?1'1i9.,Padiock:funcnnnal? — <br /> 1.Weilbox is crushed/damaged? 14. Well cap found secure? <br /> Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well I.Q. Deficiency Corrective Action Taken <br /> Note below all defiencies that could not be corrected and stili need to be corrected. <br /> BTS Office assigns or Date Data <br /> Well I.D. Persistin Decten defers Correction to: assigned corrected <br />