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WELLHEi 'INSPECTION CHECKLIST AND R—.-"AIR ORDER <br /> Client �` �� .- _ — _ T Inspection Date <br /> t <br /> Site Address �'� [ r � -�_ S _ Inspected B , l <br /> 1.Ud on box? 6. Casing secure? 12. Water standing In wellbox? 15.Well cap functional? <br /> 2 Lid broken? 7. Casing cut Isvel7 12a.Standing above the top of casing? 18.Can cap be pulled loose? <br /> 3.Lid bolts missing? a. Debris In welibox? 12b.5lending below the top of casing? 17.Can cap seal out water7 <br /> 4.Lid bolts stripped? 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 tao tar below grade? 13. Well cep present?, 19.Padlock functional? <br /> 11.Wellbox Is crushed/damaged? 114. Well cap found secure? <br /> Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well I.D. <br /> DefiGiengy Corrective Acton Taken <br /> Note below all defiencles that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficient defers Correction to: assigned corrected <br />