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WELLHE iNSPECTiON CHECKLIST AND 1- ,'AIR ORDER <br /> Client— !s4l <br /> Inspection Date 8-23-0 Z <br /> Site Address & ZO dq , Inspected By • <br /> 1 Lid an 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 tnp of using? 16 Can cap be pulled loose? <br /> 3.Lid bolts missing? B Debris In wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stepped? 9 Wellbcx Is too far above grade? 12c Water even wish the top of casing? A Padlock present? <br /> 5 Lid seal intact? 10,Wellbox Is too far below grade? 13. Well cap present? 19.Padlock functional? <br /> 11=Wellbox Is cmhedfdamagedt� 14:Well cap found secure? <br /> 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 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 />