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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client J� Inspection Date - " 0 j <br /> Site Address Tr��+ rA Inspected By <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap functional?- <br /> 2 Lid broken? Casing cul lever 12a Standing above the lop of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <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 Ilbox is too far below grade? 13 Well cap present? 19�Padiock functional? <br /> 11 Wellbox is crushed/damaged? 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 jAction 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 Deficiency defers Correction to assigned corrected <br />