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I, <br /> WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Inspection Date 1- <br /> Site Address- :14 o �a It. (Z",10 a., Inspected By <br /> 100, <br /> 1.Lid on box? 6. Casing secure? 12. Water standing in wellbox? 15.Well cap functional? <br /> 2.Lid broken? T. Casing cut level? 12a_Standing above the top of casing? 16_Can cap be pulled loose? <br /> 3.Lid bolts missing? S. Debris in wellbox? 12b.Standing below the top of casing? 17.Can cap seal out water? <br /> 4.Lid bolts stripped? 9. Wellbox is too far above grade? 12c.Water even with the top of casing? 18. Padlock present? <br /> S.Lid seat 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 /> Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well l.D. Deficiency Corrective Action Taken <br /> w-t l4 <br /> 1� <br /> w-2 <br /> t <br /> Note below all defiencies 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 />