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WELLHLr,u) INSPECTION CHECKLISTAND f ,;PAIR ORDER <br /> Client ,��_ _ _ _ Inspection Date <br /> Ste Address—' 20 4!f-1/eMsh Lane, 4ye , _ Inspected By,--Ey <br /> 1 Lid on box? S. Casing secure? 12. Water standing in wellbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? Va.Standing above the top of casing? 16.Can cap be pulled loose? <br /> 3.Lid bolts missing? 0. Debris In wellbox? 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 evan with the top or casing? 18 Padlock present? <br /> 5.Lid seal intact? 111.Wellbox Is too far below grade? 13. Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? J14. Well cap 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 /> r <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 Deficiengy defers Correction to: assigned corrected <br />