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WELLHE�. INSPECTION CHECKLIST ANC _.,JAlR ORDER <br /> Client AkLD SY SO Inspection Date q/11 O Z <br /> i <br /> Site Address 1617 W ,r+ o,�-� S-�p�Oo t inspected BY AA. M <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 loose? <br /> 3.Lid bolts missing? B. Debris in w 1 <br /> of box? <br /> 12b.Standing below the top of casing? 17. Can cap seal out water? <br /> 4. Lid bolts stripped? 9. Wellbox is too far above grade? 12c.Water even with the top of casing? 18. Padlock present? <br /> 5. Lid seal intact? 10.Wellbox is too far below grade? 13, Well cap present? 19, Padlock functional? <br /> 11.Wellbox is crushed/dam ag ad? 14. Well cap found secure? <br /> 0 Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> i <br /> Well I.D. Deficiency Corrective Action Taken <br /> M k)-0z tiJv Ck 2G l,�,cCc t L—ocltr <br /> Note below all defiencies that could not be corrected and stili need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to, assigned corrected <br />