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A �+ WELLHE- INSPECTION CHECKLIST AND R"FAIR ORDER <br /> Cifent _ Inspection Date_ TA-aa <br /> AddressLG Inspected By <br /> 1 Lid on box? 5 Casing secure? 12. Water standing In wellbox? 15 Well cap functlonal? <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 Debris In wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4.Lid bolts stepped? 9 Wellbox Is loo far above grade? 12c.Water even with the tap of cosing7 18 Padlock present? <br /> 5 Lid seat Intact? 10 Wellbox is too far below grade? 13 Wall cap present? 19 Padlock func0onal? <br /> 11 W-"'- is crushedldamaged? 114 Welicap found secure? <br /> Check box If no deficiencies were found Note below deficiencies you were able to correct. <br /> Well I.❑ Deficlencv Corrective Action Taken <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 />