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vvct,LJ-I t=/ 1N6PEUTION CHECKLIST AND F- 1AIR ORDER <br /> Client <br /> Inspection Date l� <br /> Site Addres / ., Inspected 8y ~ . <br /> 1 Lid on box? (i Casing secura7 I12. Water standing in wellbox? i5.Well cap functional? <br /> 2 Lid broken? 7. Casing cut level? 12a Standing above the tnp of casing? iii Can cap be pulled loose? <br /> 3 Lid bolls missing? ti Debris in wellbox7 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox Is too Isar above grade? 12c.Water even with the leap of casing? 18.Padlock present? <br /> 5 Lid seal Intact? 14.Wellbox Is too far below grade? 13 Wag cap present? <br /> 19 Padlock iuncdonal? <br /> 11.Wellbox Is ovshedldamaged7 114 Well cap found secure? <br /> Check box If no deficiencies were found Note below deficiencieso <br /> y u were able to correct. <br /> Well I.D Deficiency Corrective Action Taken <br /> I <br /> 1 <br /> Note below all defiencies that could not be corrected and soil need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> i <br />