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WELLHEAD INSPECTION CHECKLIST AND REQ ,V,IR ORDER <br /> Client 6.a.�. _ Inspection Date <br /> Site Address ,?�rS Ces,�,(r.r C,� _� 1 -r Inspected By <br /> 1 Lid on box? 6 Casing secure? 12 Watar standing in wellbox7 15 Weil cap functiona(? <br /> 12 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 can cap be pulled loose <br /> 13 Lid bolts missingl 6 Debris In wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 f id bolts stripped? 9 Welibox 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 grsde? 13 Well cap present? 19 Padlock functlonai') <br /> 11 Wcllbox 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 /> Weil 1 D Deficiency Corrective Action Taken <br /> Aar- 9 71"4) <br /> - <br /> r <br /> Note below all def€encles that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well 1 D Persisting DeftlenGy defers Correction to asst ned corrected <br /> 3 <br /> i <br /> 1 <br /> a T 7gVa <br />