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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Inspection Date —4 <br /> ti <br /> Wite Addressyze �QC. — y .9C <br /> �_ �•, inspected B <br /> 1 Lid o^box? 6 Cas ng secure? 12 Water standing in welibox? 15 Weff cap functional? <br /> 2 Lid broken? 7 Cas,ng cut level-, 12a standing soave the top of casing's i 6 Can cap be pulled loose? <br /> 3 Lid bolts missing? c Debris in weilbox? '2!) Standing below the top of casirg? 17 Can cap seat out Iva+e.? <br /> 4 Lid bolts strippea? ° VVel box is too ia;above grade? 12c Wate•even with Lhe LOP of casing? 18 Paolock present? <br /> 5 L d seal intact? 10 +Nelibox is too far below grace? 3 Well cao present? 19 Padlock functional? <br /> 11 Weilbcx is c%ishedldamaged? 14 Weil 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 Taken <br /> I <br /> I <br /> Note below all defiencles that could not be corrected and still need to be corrected <br /> nTS Office assigns or Date Date <br /> hlNelllPersisting Deficiency defers Correction to assloned corrected <br /> l <br /> s <br />