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WELLH,' INSPECTION CHECKLIST ANE ,PAIR ORDER <br /> Client <br /> — 1 Inspection Date - -D z -1 <br /> Site Address 791D I-eUrr Inspected By <br /> 1 Lid an box? B Casing secure? 12 Water standing In wellbox? 15 Well cap fund bnal7 <br /> 2 Lid broken? 7 Casing cut Ieve17 12a.Standing above tate top of casing? 16 Can cap be puffed loose? <br /> 3.Lld bolts missing? S. Debris In wellbox? 12b standing below the tap of casing? 1T Can cap seal out water? <br /> 4.Lid hafts shipped? 9 Wellbox Is too far above}grade? 12c Water even with the tap of casing? 18 Padlock presenl? <br /> 5.Lld seal lntact7 10.Wellbox Is too far below grade? 1 a Well cap present? - 19 Padlock functional? <br /> 11 %A)'-[box Is crushed/damaged? 114. Well cap found sewra? <br /> 0 Check box if no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective ACUQn Taken <br /> Note below all deftencies that could not be corrected and still need to be corrected, <br /> BTS Once assigns or Date Date <br /> Well I D. Persist-Ingi Deficiency defers Correction to assigned corrected <br /> AM 9 eh?e d r I 1 <br /> 975 <br /> ra c ► �nG <br /> �E to r-,q <br /> i <br />