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WELLHL ., INSPECTION CHECKLIST AND . . PAIR ORDER <br /> Client_ � inspection Date <br /> je; Address /2) �/ f,� .S /�/lt�Tz���r' Inspected By <br /> 1 Lid an box? 6 Casing secure? 12, Water standing In wetlbox? 1s Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3.Lid bolts missing? 8 Debris in wellbox? M Standing below the top of casing? 17,Can cap seal out water? <br /> 4 Lid bolts shipped? 9. Wailbox Is too far above grade? 12c water even with the top of casing? 18 Padlock present? <br /> B Lid seal Intact? 10 Wellbox is too far below grade? 13 well cap present? - 13 Padlock functional? <br /> 11.Wallbox Ip crushed/damaged? 114 Well cap found secure? <br /> Check box it no deficiencies were found Note below deficiencies you were able to correct <br /> Well I.D_ Deficiency Corrective Action Taken <br /> Note befow all defiencies that couid not be corrected and still need to be corrected <br /> BTS Office assigns or Date Dale <br /> Well 1 D Persisting Deficiency defers Correction to: assigned corrected <br />