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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client VM Inspechnn Date— lU�3 D/D <br /> �_ t _ {L._ _L. • <br /> Site Address - Inspected By. Ok <br /> 3� � ernl _ <br /> 1 Ltd on box? B Casing secure? 12 Water standing In wellbox7 15 Well cap functional? <br /> 2.Lid broken? 7 Casing cul level? 12a Standing above the top of casing? 10 Can cap be pulled loose? <br /> 3 Lid bolts missing? a debris In wellbox7 12b Standing below the lop of casing? 17 Can cap seal out water? <br /> 4.Lid bolts stripped? 9 Wellbox Is too far above grade? 12c Water even with Ilse top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grads? 19 Well cap present? 19 Padlock functional? <br /> :111 Wellbox Is crushed/damaged? 14 Well cap round secure? <br /> Q<1 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 deflencles that could not be corrected and still need to be corrected. <br /> BTS Ofilce assigns or Date Date <br /> Well I D. Persisting Deficlen2y defers Correction to: assigned corrected <br />