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WELLHEHO INSPECTION CHECKLIST AND kr-PAIR ORDER <br /> Client---- .yl: V n Inspection Date_T/1 $1 _ <br /> Address 2494 FrMad LS�. — Vacithyl inspected By lie <br /> 1.Lid on box? 6 Casing secure? iz 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 p0ed loose? <br /> 3. Lid bolts missing? B Debris In wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4.Ud bolls stripped? 9 Welibox is ton far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5.Lid seal Intact? 10 Watlbox Is too far below grade? 13 Well cap present? 19 Padlock funcliorml? <br /> 11 Welibox Is crushedldamaged7 114 Well cap found secure? <br /> Check box if no deficiencies were found. Dote below deficiencies you were able to correct <br /> Well LD Deficiency Corrective Action Taken <br /> Note below all defiencles 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: assigned corrected <br />