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WELLH�-hLj INSPECTIOI, CHECKLIST AND REPAIR ORDER <br /> Cfient--i C+t 1-Vol Inspection Date Z b-1/02 <br /> Site Address {jib U:�1 � Loc ; _ Inspected By K. I�dre� <br /> 1 Lid on box? B Casing secure? 12. Water standing in waribox? 15 Well cap functional? <br /> 2.Lid broken? T. Casing cut level? 12a Standing above the top of casing? 1113 Can cap be puffed loose? <br /> 3.Lid baits missing? e. Debris In wallbox? 12b.Standing below the top or casing? 17.Can cap seal out water? <br /> 4 Lid bolts stripped? 9. Wellbox is too Tar above grade? 12c Water even with the top of casing? 1 H Padlock present? <br /> 5 Lid seal intact? 10.Well box Is too Far below grade? 13. Well cap present? 19.Padlock funcQonal? <br /> 11.Wellbox is crushedldamaged? 14. Weil mn round secura? <br /> Check box if no deficiencies were found. Note below deficiencles ou <br /> _ _ ly were able to correct. _ <br /> 1!4lelf I.D. Deficiency - J Corrective Action Taken E c �Li v <br /> wAnv . 7002 <br /> L1Yvu.�. <br /> PERII T/SERVIGES <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 DeficleneX defers Correction to: assigned corrected <br /> �s� <br />