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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> , 3 e j;— <br /> Clideot v, Inspection Date 10 r' t <br /> S1teAddress LU ? [ ���� _ J�'• !''�►�tL�+� _ Inspected By a f <br /> Won box? 6 Casing secure? 12 Water standing In wellbox? 15 Wall cap functional? <br /> Z.Lfdbroken? 7. Casing rut level? 12a Standing above the tap of casing? 16 Can cap be pulled loose? <br /> 3 L idbolts missing? a Debris In wellbox? 12b Standing below the lop of casing? 17 Can cap seal out water? <br /> 4 Lidbclts stripped? g Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5,Lidseal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> III Wellbox Is cruehedldamaged7 114 Well cap found secure? <br /> E4Check box if no deficiencies were found Nate below deficiencies you were able to correct <br /> Well} 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 Date <br /> Well I.D Persisting Deficiency defers Correction to essi ned corrected <br />