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f <br /> WELLHEr„J INSPECTION CHECKLIST AND Rt✓PAIR ORDER <br /> I, <br /> Client <br /> rr -y-�'_""` _ Inspection Date a� <br /> Site Address LfKU Q. G 1^•.-- ze- Inspected By <br /> 12L!Itd <br /> d on box? 6 Casing secure? 12. Water standing in weilbox? 15 Well cap functional? <br /> broken? 7 Casing cut levet? 12a.Standing above the top of casing? 16 Can cap be pulled loosa7 <br /> d bolts rnlssing? 8 Debris In wellbox7 12b.Standing below the top of casing? 17 Can cap seal out water? <br /> 4.Lid bolts stopped? 9 Wellbox is loo far above grade? 12c.Water even with the top of casing? 18 Padlock present? <br /> 5.Lid seal Intact? 10 Wallbox Is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushedidamaged? 14 Well cap found secure? <br /> EACheck box If no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well f D. Deficiency Corrective Action 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 /> 4 1 t 4 g 70 <br /> rr� <br />