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I ILAN UMl=UKL151 ANU h"lAIR ORDER <br /> Client �7 �� Inspection Date LD I 07 <br /> Site Address ZS-75- <br /> I �u,,, b <br /> K S le.fo&t. Inspected BY A4. A--f`G�a <br /> 1. Lid on box? _ B. Casing se�sp 12. WatarstandEng in walfbmc? <br /> 2 Lid broken? 15.Well cap funcflonal? <br /> 7. Casing cut Level? 12a Standing above the top of casing7 16.Can cap be pulled loose? <br /> 3 Lid belts missing? B Debris In wellbox? 12b Standing below the top of casing7 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9. Wepbox Is too far above grade? 12c.Water even with the by of casing? 18.Padlock present? <br /> 5 Lid seat Intact? 10 Welibox is too far below grade? 13. Well cap present? <br /> 19.Padlock functional? <br /> 11.Wellbore Is ctc�shedldarnaged7 14.—Watt cap found secure? _ <br /> 0 Check box if no deficiencies were found. Note below deficiencies you were able to correCt. <br /> Well I.D Deficiency Corrective Action Takers <br /> f4 k7.4 IS.-&he.% Ca lea a I&e. d <br /> 64, <br /> AF <br /> Note below all deffencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficl ancy defers Correctlon to: assigned corrected <br /> ick wv r' <br />