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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Vic, _ Inspection Date — <br /> Site Address_'I-S75* Couw+`hy Glue Sime-ICtehInspected By 1k, <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? 122 Standing above the top of casing? 18 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5-Ltd seal intact? 10-Wellbox is too far below grade?= 13=Well cap present? 1 9-Padlock functi6nah <br /> 11 Weilbox is crushed/damaged? 114 Well cap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> MI...,�► <br /> tot•^• y ~ Ls. <br /> 1 <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 Defici22cy defers Correction to assigned corrected <br /> �+ do <br />