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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER y� <br /> Client K f 1eh Inspection Date I f Z 1YO/ <br /> Site Address /Z,67 Co-owde e ~��dc 1C"yn Inspected By gems i h <br /> 1.Lid on box? 6. Casing secure? 12. Water standing In welibox7 15.Well cap functional? <br /> 2.Lid broken? 7. Casing cut level? 12a.Standing above the top or casing? 16.Can carp be pulled loose? <br /> 3.Lid bolls missing? 8. Debris In wallbox? 12b.Standing below the tap of casing? 17.Can cap seat out water? <br /> 4_Ltd bolts stripped? 9. Wellbox is too far above grade? 12c.Water even with the top of casing? 18.Padlock present? <br /> 5.Lid seaUntact? 10.Wellbox Is loo far below grade? .13._Well.caft_present7 19.:P_adlock:functional? — <br /> 11.Wellbox Is crushed/darnaged? 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. beficlency 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 Deficient defers Correction to: assigned corrected <br />