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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> G lent Jl'V - Inspection Date_ <br /> Address 3 `11 E, pt.: S f. 46 lel _ _- Inspected By rl, <br /> 1.Lid on box? 6. Casing secure? 12. Water standing In wellbox7 15.Well cap functlonal7 <br /> 2.Lid broken? 7. Casing cut level? 12a.Standing above the top or casing? 15.Can cap be pulled loose? <br /> 3.Lid bolts missing? a. Debris in wellbox7 12b.Standing below the top of casing? 17.Can cap seal out water? <br /> 4.Lid bolts stripped? 9. Wellbox Is too for above grade? 12c.Water even with the top of casing? 18.Padlock present? <br /> S.Lid seal Inlact? 10.Wellbox Is too far below grade? 13. Well cap present? 19.Padlock functional? <br /> 11.Wellbox is crushed/damaged? 14. Well 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 /> Note below all deflencies 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 correcled <br />