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WELLHEf,,j INSPECTION CHECKLIST AND I .-PAIR ORDER <br /> ant ! Inspection Date <br /> D <br /> .ite Address 3 10). -_j,h _ 9 .lf69"'inspected By <br /> 1.Lid on box? 8. Casing se pre? 12. Water standing In wellboV 15.Well cap functimal? <br /> 2.Lid broken? 7. Casing cut level? 12s.Standing above the top of casing? 16.Can cap be pined loose? <br /> 3.Lid bolts missing? 8. Debris In wellbox? 12b.Standing below the top of casing? 17.Can cap seat out water? <br /> 4.Lid bolts stripped? 9. Wepbox is too far above grade? 12c.Water even with the top of casing? 18:Padlock pre ed? <br /> 5.Lid seal Intact? 10.Wellbox is too far below grade? 13. Well cap present? 19.Padlock Amckmal? <br /> 11.Wellbox ir:crushedldame ed? 14. WeN ca found secure? <br /> Q Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all defiencies 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 />