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VVELLHL. ,u INSPECTION CHECKLIST AND r.,.:PAIR ORDER <br /> Cliental•-, <br /> . I inspection Date lf'l `f/-Y L <br /> L. . L �. <br /> Site Address ��¢ l;,l. �."c t-E��..-,�. ., a � inspected By . <br /> rb ? B. Casing secure? 12, Water standing In wellbox? <br /> ? 1S.Wen cap functlonai7 <br /> 7. Casing cuf level? 12a.Standing above the top of casing? 16.Can cap be pulled loose? <br /> issing? B. Debris In wellbox? 12b.Standing belaw the tall)of casing? I. <br /> Can cap seal out water? <br /> Lid <br /> tripped? 9. Weilbox is too far above grade? 12c.Water even with the top of casing? i 6.Padlock preseM7tact? j <br /> 10.Wellbox Is too far below grade? 13. Wall cap present? <br /> 11.Wellbox i5 Mshedldamaged? 14. Well cap found secure? 19padlock fvnefinnal? <br /> 1 <br /> Check box if no deficiencies were found. Note below deficiencies you were able to correck � <br /> Well I.D. ©efficiency Corrective Acton Taken <br /> I <br /> Note below all def encles that could not be corrected and stili need to be corrected. , <br /> BTS Office assigns or Date Date <br /> We/, <br /> f111.0. Perlis n Deficiency <br /> defers Correction to: asslaned corrected <br /> , <br /> • I <br /> I <br /> . i <br />