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INELLHE 1 INSPECTION CHECKLIST ANY .-PAIR ORDER <br /> Cllent� �_ inspection Date <br /> Site Address SicA c:yr Inspected By <br /> �1.kon box? 6. Casing secure? 12. water Mending In wellbox? 16.Well cap fund mal? <br /> 2. LId broken? T. Casing cut level? 12a.Standing above the top of casing? 16.Can cap be pulled louse? <br /> 3. Lid bolts missing? 0. Debns In welibox? 12b standing balaw the top of casing? 17 Can cap reef out water? <br /> 4 Lld bolts shipped? 9. Wellbox Is too far above grade? 12c.Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal Intact? 10.Wellbox Is too far below grate? 13 Well cap present? - 19 Padlock functional? <br /> 11.Wellbox Is crushed/damaged? 14. Well 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 Taken <br /> Yh r`es� <br /> �Q- <br /> V <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. Persistin-gDeficlency defers Correctlon to: assigned corrected <br /> Tol <br />