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WELLHEA INSPECTION CHECKLIST AND R. 'AIR ORDER <br /> Client <br /> Inspection Date <br /> Site Addressr-Our-:7- ah;ck_ - - c�e� Inspected By <br /> IF <br /> 1 Lid on box? 6. Casing secure? 12 Water standing In wellbox? 15 well cap functional? <br /> 2.Ltd broken? 7 Casing out level? 12a Standing above the by of casing7 16.Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris In wellbox? 12b Standing below the lop 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 rasing? 18 Padlock present? <br /> 5 Lid seal lntac17 10 Wellbox Is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 WellbDx Is crishedldamaged? 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 /> Note below all deflencies 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 /> ¢.r-3 <br />