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WELLHEt,,, INSPECTION CHECKLIST AND kizPAIR ORDER <br /> Client inspection Date---- 7-1a•v'Z� <br /> Site Address. 2575_ rn ..,,Ar, cInspected By a"IC <br /> 1 Lid on box? 6 Casing secure? 12. Water standing in wellbox? 15.Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 15 Can cap be pulled loose? <br /> 3 Lid bolts missing? tl Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seat out water? <br /> 4 Lid bolts str1pped7 9. Wellbox Is too far above grade? 12c.Water even with the top of casing? I&Padlock present? <br /> 5 Ltd seal intact? 1 a Wellbox Is too far below grade? 13 Well cap present? 19.Padlock functional? <br /> 11=Wellbox Is crushedldemaged?=114:—,—Well-cap faun "secure? <br /> Check box If no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well I D. DeficiencyCorrective Action Taken <br /> t11J-1� i3.-,,[, .. <br /> Note below all 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 /> Lo <br /> 3..^ 1/1� <br /> X gn4 <br /> ��� —! Z,)4e-t♦ w ��Gl �1 <br />