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WELLHEAD INSPECTION CHECKLIST AND REFAIR ORDER <br /> Client—.9 P.. Inspection Date �7[fir t 0 IL _ <br /> Site Address 2 C,7- k-A-) (ArL L-,lV-,L-,V" 1 01 Inspected By <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 lop of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolls missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seat out water? <br /> 4 Lid bolts stropped? 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 Deficient Corrective Action Taken <br /> jvC �Jt ti. f C t' RL o <br /> Note below all defencles 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 />