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i <br /> WELLHL A,j INSPECTION CHECKLIST AND' <br /> REPAIR ORDER <br /> Client Inspection Date <br /> *Address W. �s �e�ttM+r art. Lia; I /o{ <br /> Inspected By �y n <br /> 1 1d on box? 6 Casing secure? 12 Water slanding in walibox? 15 Well cap functional? <br /> 2.Ud broken? 7. Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 1 T 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? 1 B Padlock present? <br /> 5 I_1d seal intact? 10 Wellbox Is too far below grade? 13 Well cap present? 19.Padlock functional? <br /> 11 Wellbox Is crushedldamaged? 114 Well cap found secure? <br /> LAJ i <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 /> Note below all defiencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Dale <br /> Well I D Persistrig Deficiency defers Correction to assigned corrected <br />