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AUG 2 2001 <br /> WELL'�E4D INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client—&,,)/-t- inspection Date <br /> Oe Address 5_�5` L'_ 1, _;ii GSI Inspected Sy <br /> v <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? 12a Standing above the top of casing? 16 Can cap be pulled Ieose? <br /> 3 Lid bolts missing? 8 Debris in weilbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stepped? 9 Wellbox is too far above grave? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seat intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crush edldamageo? 14 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 /> 1 <br /> I <br /> I � <br /> Note below all defiencles that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> kWell I D Persisting Defclencv defers Correction to assioned carrec.ed <br /> I <br />