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WELLHEA,, iNSPECTION CHECKLIST AND REPAIR ORDER <br /> „Ghent Wr 4� .+:rj•e,�rf`•l �-/-�y-,rrl <br /> Inspection Date <br /> tie Address .S� �` 1�1e.a.�f� J '1. Tn <br /> Inspected By •110., <br /> 1 Lid on box? 6 Casing secure? <br /> 12 Water standing in wellbox? 15 Well cap runciionai? <br /> 2 L d broken? 7 Casing cut level <br /> i2a Standing above the top of casing-, 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in vellbox? <br /> 12b Standing below the top of casing? 17 Can c , <br /> 4 Lid bolts stripped? g Wellbcx is too far above rade? Cap seal out water? <br /> g 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Welrbox is tco fol belowrade? <br /> q 13 Well cap present? 19 Padlock functiena!? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secire? <br /> 0 Check box If no deficiencies were found Note below deftctencies you were able to correct <br /> Well I D Deflctency Corrective Action Taken <br /> Note below all deftencies that could not oe corrected and stiff need to be corrected <br /> BTS Office assigns or Date Date <br /> 'Alell I D Persisting Deficiency defers Correction to <br /> ass,aned corrected <br /> � <br /> AV-7 44 <br /> ,,�lci• 9 ��� � �.1 Ff .� a r�%Sle �• <br /> f <br />