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VVCLLrlL F IlV7I-'Cly l IUI� l�l'7CVI�L[7i fil�tEi F'HIIi U1�lJCK <br /> ClientInspection Date <br /> Site Address 1/;C) 1.J. k[U _ [ �e .' _ inspected By— _ <br /> 1.Lid on box? 6. Casing secure? 12. Water standing In wellbok? 15.Well cap functional? <br /> Z.Lid broken? 7. Casing cut level? 12a.Standing above the top of casing? 16,Can cap be pulled loose? <br /> 3.Lid bolts missing? B. Debits In wellbox? 12-b.Standing below the top of casing? 17.Can cap seal cut water? <br /> 4.Lid bolts stripped? 9. Welibox Is too far above grade? 12c.Water even with the top of casing7 i8.Padlock present? <br /> 5.Lid seal Intact? 10.Welibox Is too far below grade? 13. Well cap present? 19.Padlock funcilonal? <br /> 11.Wellbox is crushed/damaged? 14. Well cap lbund secure? <br /> Q Check box If no deficiencies were found. Mote below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all defiencles that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Dale <br /> Well I.D. Persisting Deficiengy defers Correction to: assigned corrected <br /> M0-G ADM h, � o41 4r4 *rs 7y <br /> nctc.� -AekJ UeJ <br />