Laserfiche WebLink
.�. w WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br />Client_ p <br />_ Inspection Date_. <br />Site Address U <br />Inspected By <br />, <br />1. Lid on box? <br />6. Casing secure? <br />12_ Water standing in wellbox? <br />15. Well cap functional? <br />2_ Lid brokers? <br />7. Casing cut level? <br />12a. Standing above the top of casing? <br />16_ Can cap be pulled loose? <br />3. Lid bolts missing? <br />8. Debris in wellbox? <br />12b. standing below the top of casing? <br />17. Can cap seat out water? <br />4. Lid bolts stripped? <br />9. Wellbox is too far above grade? <br />12c. Water even with the top of casing? <br />18_ Padlock present? <br />5. Lid seal intact? <br />10. Wellbox is too far below grade? <br />13. Well cap present? <br />19. Padlock functional? <br />J, >!k 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 defiencies 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 />