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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client qjInspectionDae 01 <br /> Oe Address '7 110 1- S-c�vv�:r~a+•, Inspected By_ w a nk Q <br /> 1 Ltd on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap functional? <br /> 2.Lid broken? 7 Casing cut level? 12e Standing above the top of easing? 18 Can cap be pulled loose? <br /> 3.Ltd bolts missing7 8 Debris In wellbox? 12b.Standing below the top of casing? 17 Can cap seal out water? <br /> .Ltd bolts stripped? 9 Wellbox Is too far above grade? 12c Water even with the top of casing? -18 Padlock present? <br /> 5 Lid seal Intact? 10 Wellbox Is too tar below grade? 13 Well cap present? 19.Padlock functional? <br /> 11.Welibox Is crushedldarnaged? 114. Well cap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D. Deficlen2y Corrective Action Taken <br /> Note below all deflencles 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 /> r <br />