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WELLHE, INSPECTION CHECKLIST AND r._ 'AIR ORDER <br /> Client 13P`n Inspection Date ILF t Z <br /> 0 Site Address 11/6 01 fir• a r— c"t$s ected By )L4.M C6Ct1-' <br /> 1 Lid on box? 6 Casing secure? 12 Water standingweflbox? <br /> in 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? 8 Debns in welibox? 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/damaged? 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 Action Takers <br /> ` (f-do- <br /> in <br /> )a Lil-CA 04 <br /> Nle-� cam. �4eId <br /> �.+>c.�� c-•� <br /> i <br /> Note below all defienctes 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 />