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WELL—HE,.— INSPECTION CHECKLIST AND h,-'AIR ORDER <br /> Client_ SiL.Q 1' _ Inspection Date 7 11ILa Z <br /> Site Address �_sa. t�6 , c5rot� yJt Inspected Hy Ali, okJAII's <br /> 1 Lid on box? 6 Casing secure? 12. Water standing In wellbox? 15 Well rap functional? <br /> 2-Lid broken? 7 Casing cut level? 12a.Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts[Hissing? 8, Debris In wellbox? 12b Standing below the top of casing? 17.Can cap see]out water? <br /> 4 Lid bolts stopped? 9 wellbox Is too for above grade? 12c.Water even with the top of casing7 18 padlock present? <br /> 5 Lid seal Intact? 10.Welibox is too far below grade? 13 Wel]cap present? 19 Padlock functional? <br /> III Wellbox Is crushed/damaged? 114 Well cap found secure? <br /> 0 Check box If no deficiencies were found. Note below deficiencies you were able to correct, <br /> Well I.D. Deficiency Corrective Action Taken <br /> I <br /> I <br /> I <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. Perslsflng Deficient defers Correction to. assigned corrected <br />