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WELLHEI INSPECTION CHECKLIST AND F.__.-IAIR-ORDER --_ - -- - <br /> Client — Inspection Date-7--- - <br /> Site Addressy_e Inspected By <br /> 1.Lid an box? 5 Casingsecure? <br /> 12. Water standing in wallbox? 15 Well cap funntiatral? <br /> Z Ltd 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 welltrox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4.Lid baits stripped? 9 Wellbox Is loo 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 Wall cap present? 19 Padlock funcllonai? <br /> 11 Wellbox Is crushadldernaged? 14_ Well cap found secure? <br /> Check box if no deficiencies were found. Note below deficiencies you were able to correct, <br /> Well LD Deffclency Corrective Action Taken <br /> Note below ail defiencies that could not be corrected and stili need to be corrected. <br /> BTS Office assigns or -Date Date <br /> Well I D. Persistin Deticienc defers Correction <br /> to. assigned corrected <br />