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WELLHEAD OPECTION CHECKLIST AND REFO ORDER <br /> Client --5- <br /> ZInspectlan ©ate7 '"�� <br /> ,Site Address _9 / Inspected: By <br /> 1 Lid:r hex? o Casing secure? 12 V'a,ter standing in wellbor? 15 Weil cap functtonai <br /> 2 Lid Broken 2 7 Casina cut level? 112a Ste^d ng Rnove the top of casing? .6 Can cap be puled loose? <br /> 3 Lid bolts missing? 8 Debris in wet;box% 12b S+andtna below the top of cas,rg? 17 Can cap Seal out,vete-? <br /> 4 Ltd bolts stripped? 9 'Vellbox is Log zar above grade? i 2c Wate-ever wits, the top oz casing? 18 Paolock present? <br /> 5 Leo seal intact? 10 Wellbox is toe far below grace? .3 Wel cap present? 19 Padlock functional? <br /> 11 iNellbor .s c-L-shed/dar^aaed? 14 Well cap found sec ire? <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 /> i <br /> Note below all defencles that could not be corrected and still need to be corrected <br /> 'OTS Office assigns cr Date Date <br /> Well i D Persisting Deficiency defers Correction to assigned corrected <br /> i <br />