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WELLHEt _ INSPECTION CHECKLIST AND Fc�,'AIR ORDER <br /> Client ��e If Inspection Date <br /> Site AddreSS, to�A)`Q,r SCIC, Inspected By <br /> 1 Ud on box? B Casing secure? 12 Water standing In wellbox? 15 Well cap functlonal? <br /> 2. Ud broken? 7 Casing cut level? 12a.Standing above the top of casing? 15 Can cap be pulled loose? <br /> 3 Ud bolts missing? 9 Debris In wellbox? 12b.Standing below the top of casing? 17 Can cap seal outwater? <br /> 4 Ud bolts stripped? 9 Wellbox Is too far above grade? 12c Water even with the tap of casing? 16 Padlock present? <br /> 5 Ud seal Intact? 10.Wellbox Is too Far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox Is crushed/damaged? 114 Well cap found secure? <br /> UTCheck box If no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well LD Deficiency Corrective Action Takers <br /> i <br /> Note below all defiencies that could not be corrected and stlil need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficlenq defers Correction to: assigned corrected <br />