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F ` WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Hent-92t-f 'q Inspection Date Z~l a <br /> • <br /> Site Address rt inspected B <br /> 17> <br /> 1 Lid on box? F <br /> ecure? 12 Water standinrn welibox?9 15 Well cap functional?2 Lrd broken? ut level? 12a Standing above the top of casin �3 Lid bolts mrssrn 9 16 Can cap be pulled loose?9 welibox? 12b Standing below the top of casing? 17 Can cap seat out water?4 Lrd bolts stripped? s too far above grade? 12c Water even with the to of casin ?5 Lrd seal intact? p 9 i8 Padlock present? <br /> is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> is crushedf,4— ed? 14 Weil cap found secure? <br /> Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well i D DeficienclyCorrective Action Taken <br /> K C <br /> �lw 3 � ffr! s�--cam J-oe-z <br /> �t <br /> Note below all defiencles that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persistin Deficiency defers Correction to asst ned corrected <br />