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fr WELLHE. INSPECTION CHECKLIST AND �,"b'AIR ORDER <br /> Client -e�t Inspection Date <br /> a Z�_X_ <br /> i <br /> Site Address 7 700 ltiart4a,%�d �. � spet,ted By . 1 Ae-C-, .� <br /> 1 Lid an box? 6 Casing secure? 12. Water standing In welibox? IS Well cap functional? <br /> 2.Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16.Can cap be pulled loose? <br /> 3 Lid bolts missing? B Debris In wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts shipped? 9. Wellbox Is loo far above grade? 12c.Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal Intact? it).Welibox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox Is crushedldamaged? 114 Well cap found secure? <br /> 0 Check box If no deficiencies were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency- Corrective Action Taken <br /> X4W-2 1 )a ' t��- Alej Lot-IG <br /> Note below all defiencies that could not be corrected-and still(need to be corrected. i <br /> BTS Office assigns or Date Date <br /> Well 1 D Persisting Deficiency defers Correction to: assigned corrected <br /> i <br />