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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Chant T V& _ Inspection Date 111jala <br /> Site AddresS+. ys o r 40, _ Inspected <br /> i Lid on box? 6 Casing secure? 12. Water standing In welibm? 15 Well cap functional? <br /> Z Ltd broken? 7 Casing cut level? 12e Standing above the by of casing7 IS Can cap be pulled loose? <br /> 3 Lid bolts missing? 6 Debris in wellbox? 12b.Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Welibox is too far above grade? 12c Water even with the top of casing? 18.Padlock present? <br /> 5 Lid seal Intacl? 'ill Wellbox Is too far below grade? 13. Well cap present? 19,Padlock functional? <br /> 11 Wellbox Is q=hedldamaged? 14 Well 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 defiencies 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: assigned corrected <br />