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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client_ Inspection Date <br /> S f�4r�fi �, <br /> Site Address.,_�� 3 I,) _ j-✓�f`r�"`-� _ . _ _ Inspected By <br /> I Lid on box? 6 Casing secure? f 12 Water standing in weilbox? 15 Well cap functional <br /> 2 Lid broken? 7 Casing cut level?l/ 12a Standing above the fop of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seat out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far aboJe grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact-, 10 Wellbox is too fay beton grade' 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushedldamaged? 14 Well cap fo.ind secure? <br /> Ike Check box if no deficiencies-were found YNote below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> _ s <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 Persisbn2 Deficiency defers Correction to assigned corrected <br />