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All <br /> WELLHEAD INSPECTION CHECK IST AND REPAIR ORDER <br /> Client V4 —%R �-glrtl�7 lnspecfian ❑a# fc�' <br /> Site Address_ 6976 O- Ukr-LAla,�- c� - Inspected By <br /> 1 Ltd an box? B Casing secure? 12 Water standing In wellbox7 15 Well cap funcllnnai7 <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top or casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris In weltbox? 12b Standing below the top of casing? 17.Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox Is too for above grade? 1?_c Water even with the top or casing? 16 Padlock present? <br /> 5 Lid seal intact? 1 U.Wellbox Is too far below grade? 13 Well cap present? — 19 Padlock functlanal? <br /> 11 Wellbox Is crushed/damaged? 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 /> Nate below all defiencles that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well LD Persisting Deficlenc defers Correction to. assigned corrected <br /> I <br />