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WELLHEAD INSPECTION CHECKLIST AND REFr+rR ORDER <br /> Client_ . _ _. _ Inspection Date <br /> Site Address Tyr cr,t 7r —r-f' X�gre41_ Inspected Sy <br /> 1 Lid on box? 8 Casing secure? 12 Water standing in wellbox? 15 Well tap functional? <br /> 2 Ltd broken? 7 Casing cut lever 12a Standing above the top of casing? 16 Can cap be pulled 100607 <br /> 3 Ltd bolts missing? 8 Debris in wellbox? 12b SULridsng below the top of cssinr 17 Can cap seal out water? <br /> 4 Lid bolts sUipp0d? 9 Weiibox is too far above grade? 12c Water even with the top of casing') 18 Padlock pressnt? <br /> 5 Lid seal Intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is cnishedldamaged? 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 Acton Taken <br /> Note below all defienctes that could not be corrected and still need to be corrected <br /> BTS Ot ice assigns or Date mate <br /> Well I D Persistina Deficiency defers Correction to assigned corrected <br /> 8� 39dd SMIA83S H031 3NId'18 10 Q T6 49 E- 300Z;L--C,/�i <br />