Laserfiche WebLink
WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client +:••w — _ -- Inspection Date <br /> Site Address Li i i r u`f cr 1°` f f+ cit. 6L, inspected By,__ <br /> 1 Ltd on box? 6 Casing secure? i2 Water standing In wellbox? 15 Well cap 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 missing? a Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4.Ltd bolts stripped? 9. Watibox is loo far above grade? 12c Water even with the lop of casing? 18 Padlock present? <br /> 5 Lid seal Intact? 10.Wellbox Is too for below grade? 13 Well cap present? 19 Padlock Functional?` <br /> 11 Wellbox is crushedldamaged? 14 Well cap found secure? <br /> 0 - Check box if-no deficiencies were found. 'Note below deficiencies you were able to dorrect. - <br /> Well LD Deficiency <br /> / Corrective Action Taken <br /> e <br /> Note below all deiiencles that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> well 1 D. Persisting Deficleng defers Correction to assigned corrected <br />