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WELLH,- a INSPECTION CHECKLIST ANL .:PAIR ORDER <br /> 10 1Client��f�f,j <br /> --,— Inspection Date O r <br /> 51fe Address��� w. R�-� �.��,�5.� inspected By <br /> ,6! <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 Ltd bolts missing? B Debris In wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stnpped? 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 functional? <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 Taken <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> 1 BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to assi ned corrected <br /> M �.�c <br /> i <br /> • <br /> 1 <br /> 1 <br />