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WELLHEr INSPECTION CHECKLIST AND 14�.-,AIR ORDER <br /> Client he I Inspection Date 'g 9~ <br /> Site Address Mon '7* fi- fj ?��osected By C . rne�.lr 40, <br /> 1 LId on box? 6 Casing secure? 12. Water slanding In wellbox? 15.Well cap runctlonai? <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? B Debris In welibox7 12b standing below the top of casing7 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9. Wellbox Is Ion far above grade? 12c Water even with the top of casing? IS.PerlinTOT ? <br /> 5 Lid seal Intact? 10 Wellbox is too far below grade? 13 Well cap present? <br /> 11 Wellbox Is crushed/damaged? 14. Well cap found secure? <br /> OCT F1 o <br /> EU Check box If no deficiencies were found. Note below deficiencies you were able1JMkT HEALTH <br /> Well I D. Deficiency Corrective Action-TakenPERMIT/SERVICESI , <br /> Note below all defiencles that could not be corrected and stili need to be corrected, <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deftcien defers Correction to assigned corrected <br /> 7 <br />