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VV=Li-hl;j INSPECTION CHECKLIST AND F .,)AIR ORDER <br /> Client 54d Inspection Date °I 17 a Z <br /> Site Address -7:200 Aor t- C4. � f,�Otl Inspected By tA•I'kC&10 W . <br /> nL- <br /> 1. d on box? B. Casing secure? 12. Water standing In wellbox? 15.Well cap funational? <br /> 2.Lid broken? 7 casing cut level? 12a.Standing above the tap of casing? 18 Can cap ba pulled loose? <br /> 3.Lid bolts missing? U. Debris In wellbox? 12b.Standing below the top of casing? 17.Can cap seal out water? <br /> 4.Lid bolts Stripped? 9 Wellbox Is tory for above grade? 12a.Water even With the top of casing? 18 Padlock present? <br /> 5.Lid seal Intact? 10.Wellbox Is too lar below grade? 13. Well cap present? 19.Padlock functional? <br /> 11 Wellbox Is crushed/damaged? 114, Well cap found secure? <br /> 0 Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> i <br /> Well I.D DeAcIenGv Corrective Action Taken <br /> h4W'3 A/"s ",If, Loci <br /> Mw-ti <br /> i <br /> 1 <br /> Note below all deftencles that could not be corrected and stili need to be corrected. <br /> 6T5 Office assigns or Date Date. <br /> Well I D. Persisting Deficiency defers Correction to: assigned correcbd <br /> I <br /> r 1 4 <br /> I I <br />