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1NEf_LHE, INSPECTION CHECKLIST AND RL-,'AIR ORDER <br /> Clr?nt , g, <br /> Inspection Date 2+l d <br /> Site Address Inspected By <br /> 1 Lid on boxy 6 Casing secures � <br /> 2 Water standing In wellbCx� 15 Well cap functronal� <br /> 2 Lrd broken? 7 Cesrng cut level? 1Za Standing above the to Of cas�n <br /> 3 Lid bolts m�ssrn P Q 78 Can cap be pulled loose? <br /> 8 $ Debris,ri welibox7 S2b Standing below the tnp of casrnp7 17 Gan cap Beal outwr�Eer <br /> 4 ?rd bolts stnpped� 4 Weltbox is too far above grade? 12e Water even with the to of casing? 1 a <br /> 5 Lid seat inject? 10 vvellbox is too far below grade? 13 Well ca p 9 S Padlock present <br /> p presents 19 Padlock functional? <br /> 11 Wellbox is cruShedfdamaged? 114 Well cap found Secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well 1 p ©elect. Corrective Action Taken <br /> A <br /> ,=u f <br /> . 06 t< V, fa <br /> Note below all defienCles that could not be corrected and still need to be corrected <br /> Well I D Persistln Defcienc BTS Office assigns or Date Date <br /> defers Correction to- asst ned corrected <br />