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t <br /> � I <br /> WELLHEAD iNSPECTION CHECKLIST AND REPAIR ORDER f� <br /> Ctienl y;V.. _ Inspection Data--;S—ZJ a <br /> Site Address U� IJ• J!. �.rtcG�_ Inspected By .♦ 0•7 <br /> 1 !Ic on box? =i C,assng sac-ire? 12 'Nate standina In wellbox" 15 Well ca-n functional? <br /> 2 Lid .-)c k---, 7 Casmo r 1i'evel% 11 2a S=a^d,ng above the top of cas,ng% F Can cap be putted loose? <br /> 3 Lid bolts missmct' o r)ai,.3 r 112n S'undinc bplo,N the+op of casing-, 17 Can cap seal o it water- <br /> 4 Lid bots ctrlaperf 7 'n V ellbox Is. `,~t -r de-` 12c 'V 'er—sri wit,i tl,e coa of casing' 18- Padlock present? <br /> 5 Llri seal Intact" Ws,rticc =; cc,fa I,.ION grac:' 3 fell cap present? 19 padlock furiclinn317 <br /> 1� �lellhor�s r^�shcvfdama ed ,,A Well cap toind secure? <br /> C heck boy if no deficiencies were found Note below defc tencies you were able to correct <br /> Well I D Defic:ency Corrective Action Taken <br /> Ncte below all defipncies that could not be corrected and still need to be corrected <br /> BTS Off:ce assigns or Da+e Date <br /> Well I D Persistin DeficierTc�i _ defers Correction to ` ` assn ned corrected <br /> I <br /> I ' <br /> — n <br />