Laserfiche WebLink
WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> l <br /> Inspection Da <br /> Client <br /> I , <br /> Site Addresc c4 ✓� _._ c�`` Inspected By cti �C �� <br /> s <br /> 1.Lid an box? 5. casing secure? 12. Water standing in wellbox? is.wait cap functional? <br /> 2.Lid broken? 7. Casing cut level? 12a.Standing above the top of using? 16.Can cap be pulled loose? <br /> 3.Lid bolls missing? 8, Debris in wellbox? 12b,Standing below the top of casing? 17.Can cap seal out water? <br /> 4.Lid bolts stripped? 19. Wellbox Is too for above grade? 12c.Water even with the top of casing? 18.Padlock present? <br /> 5.Lid seal Intact? 10.Wellbox Is toff far below grade? 13. Well cap present? i g.Padlock functional? <br /> 11.Wellbox is aushadldamaged? 114. Well cap found secure? <br /> I <br /> Check box if no deficiencies were found. Note below^deficiexncles you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken � <br /> ii <br /> i <br /> 1' <br /> i <br /> Note below all defiencles 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 /> o <br /> iM � <br />