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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �}�c� Inspection Da9 odm- <br /> Site Address c� ✓ Inspected By et Ve A)e ! • <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 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? 12b Standing below the top of casing7 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 /> 5 Lid seal Intact? 10 Wellbox is too far below grade? 13 Well cap present? A Padlock functional? <br /> 11 Wellbox is crushedtdarnaged7 j 14. Well cap found secure? <br /> © Check box If no deficiencies were found Note below deficiencies you were able to correct. <br /> Well 1 D. Deficiency Corrective Action Taken <br /> Note below all defencies that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiengy defers Correction to: assigned corrected <br />