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- -- --- _ - ---- - --- --_ -- - - - --_- - -- -- - -ter---- - -- <br /> r� <br /> WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> s <br /> Client .���� _ _ Inspection Date 1 )-3 (3 -00 <br /> Site Address^ ac: Inspected By_..��1 oM yr,�w 4r <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 Lid bolts missing? 8 Debns in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stepped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> S 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 defiiencies 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 /> 1 <br />