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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �_G tet.. _ Inspection Date 3 n i 6 ] <br /> Site Address Inspected By <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> — - 3-Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbor is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellboxxiis crushed/damaged? 14TWell cap found 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 detiencies-that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well 1 D Persisting DeficiencX defers Correction to assigned corrected_ <br />