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I 1 <br /> WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER � <br /> Client ' <br /> Inspection Date - �p <br /> Site Addresscolainspected By <br /> 1 Lid on boxy 6 Casong secures71, <br /> Water standing rn weilbox? I <br /> 2 Lrd broken? 15 Well cap funcfionaf?7 Casing cut level% a Standing above the to of casin3 Lrd bolts mrssin p 9 16 Can cap be pulled toose�g 8 Debris in weffbox7b Standing below the top of casin4 Lid bolts stepped? 9 Weilbgx rs ton far abog 17 Can cap seal out water?Waiar even with the lop of casing? 18 Padlock present?Lid seal intact? 10,Wellbox is too far-bel =Weft cap present? 19 Padlock functional?11 Wellbox is crushed/dWell cap found secure? <br /> 7; Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all de€iencies 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 asst ned corrected <br />