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WELLHEA NSPECTION CHECKLIST AND REPAIR ORDER <br /> Clrertt ,�Vdl, <br /> inspection Date 1-1— 2 6 -01 <br /> �Site Address (d 7 1 N. Mips V% f {• /`�•� �'�[., Inspected By .y tu., 0 <br /> 1 Lid on boxy 6 Casingsecure <br /> 12 Wafer standing in wellbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut fevel% 12a Standing above the top of casing? <br /> 3 Lid bolts missing? 16 Can cap be pulled loose? <br /> 9 8 Debns in we€lbox7 12b Standing below the top of casing? 17 Can cap seal put wager? <br /> 4 Lid bolts stripped 9 Wellbcx is too far above grade? 12c Water even with the to of p casing? 18 Padlock present <br /> 5 Lid sea[intact <br /> 10 Wellbox is too far below grade? 13 Well cap presents 19 Padlock functional? <br /> 11 Weflbox is crushedidamaged? 14 Well cap found secure? <br /> 0 Check box if no deficiencies were Found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> t <br /> Note below all defencles 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 corrected <br />