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I tuiv Vr1l:--UKL.15 i ANU h.—.'AIR ORDER <br /> Client � 1^�►�E <br /> Inspection Date <br /> Site Address 10'7 l Inspected B <br /> R y_ .�o�-, <br /> an box? _ 6, Casing secure? 12. Water standing In welibox? is.Weil cap functional? <br /> 2 Lid broken? 7 Casing cut levet? 12a Standing above the tap of casing? 16 Can cap be puffed loose? <br /> 3 Lid bolts missing? B Debris In wellbov 12b Standing below the tog of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9. Wellbux Is too for above grade? 12c.Water even with the by of casing? 18 Padlock present? <br /> 5 Lid seal Intact? 10 Weilbox Is too far below grade? 13. Well cap present? 19 Padlock functional? <br /> i 1 Wailbox Is crushedtdamaged7 114 Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to correct:. <br /> Well LD Deflciencv Corrective Action Taken <br /> Note below all defiencies that could not be corrected and stili need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br />