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WELLHE 1 INSPECTION CHECKLIST AND _PAIR ORDER <br /> InspectionDate <br /> Site Addresszffi / i 274 r� J C r�1 _ Inspected By <br /> 1id 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 Ioase? <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 casing7 18.Padlock present? <br /> 5 Lid seal Intact? 10 Wei lbox Is too far below grade? 13 Well cap present? - 19 Padlock funcilonal? <br /> 11 wellbox is crushedldamaged7 114 Well cap found secure? <br /> Check box If no deficiencies were found. Nate below deficiencies you were able to correct. <br /> Well I.D. eficiency Corrective Action Taken <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office esslgns or Date Date <br /> Well E.D. Persisting Deftclency defers Correction to- assigned corrected <br />