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WELLK— INSPECTION CHECKLIST AND , ,EPAIR ORDER <br /> Client S y e it Inspection Date 3`oc;t <br /> e Address Inspected ey` ---- <br /> 1 LId an bax? 6 Casing secure? 12 Water standing In wellbox? 15 Well cap functional? <br /> 2.Lid broken? 7. Casing cut level? 12a Standing above the lop of casing? 16 Can cap be piAed loose? <br /> 3 Lid bolts missing? 8 Debris In wellbox? 12b Standing below the top of casing? 17 Can cap sea[ost water? <br /> 4 Lid bolts stripped? 9 Wellbox Is too far above grade? 12c Water even vrfth the top of casing? 18.Padlock present? <br /> 5 Lid seal intact? 11 wellbox Is too far below grade? 13 Weil cap present? 19 Padlock funcllana[? <br /> i i Walibox Is crushedldamaged? 14 Well cap found secure? <br /> 4 <br /> Chuck box if no deficiencies were found. Note below deficiencies you were aide to correct, <br /> We i I.D. Deficiency Corrective Action Taken <br /> Note below all deflencles that could not be corrected and still need to be corrected, <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: asst ned corrected <br />