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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> ClientInspection Date <br /> Site Address 131Pat;i c AV 41440, Inspected By Xtvih <br /> 1 Lid on box? 6 Casing secure? 12. Water standing In well box? IS Well cap runctEanal? <br /> Z Ltd broken? 7 Casing cut level? 12a.Standing above the top or casing? 16 Can cap be pulled loose? <br /> 3 Lid bolls missing? 8 Debris In wellbox? 12b.Standing below the top or casing? 17 Can cap seal out waler7� <br /> 4 Ltd bolls stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> S-Lid seal Intact? — — 10-Wellbox is too far below grade?— 13 -Well cep present? 19 Padlock functional? <br /> 11 Wellbox Is crushsd1damaged7 14 Well cap round secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all deliencies that could not be corrected and still need to be corrected. <br /> BTS Offlce assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br />