Laserfiche WebLink
f <br /> WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �ia�l _ Inspection Date O/ <br /> Site Address 7?T ✓t' AM/ T Inspected By <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap functional? <br /> - <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? 1215 Standing below the top of casing? 17 Can cap seat 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 Wellbox is too far below grade? 13 Well cap present? 19 Padlock funclionai? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action waken <br /> Note below all deftenctes 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 /> v <br />