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WELLHEAD INSPECTION CHECKLIST"AND REPAIR ORDER <br /> Client GA57 Inspection Date <br /> Addres ?crc.Xc �9✓zw S GfCfw7 Inspected By <br /> 1 Lid on box? 6 Casing secure? 12. Water standing In welibox7 15.Well cap runctional? <br /> 2 Lid broken? 7 Casing cul level? 12a Standing above the lop or casing? IS Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top or casing? 17 Can cap sea[out water? <br /> 4 Lid bolts stripped? 9 Wellbox Is too far above grade? 12c Water even with tine lop of casing? 18 Padlock present? <br /> 5 Lid seal Inlact? 10 Wellbox Is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 1 t Wellbox is crushed/darnaged7 14. Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below del'iciencles you were able to correct <br /> Well i D Deleclenc lJ Corrective Action Taken <br /> AV-l0cl/ lt1G/% <br /> r <br /> Note below all denencles that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to asst ned corrected <br />