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WELLHEE INSPECTION CHECKLIST AND k_ . 'AIR ORDER <br /> Client `lc <br /> Inspection Date <br /> Site Address__ 3'?ZS 'Fr ox— Vie. fns acted B <br /> 1.Lid on box? 6. Casing secure? 12. Water standing In wellbox? 15.Well cap functional? <br /> 2.Ud broken? 7. Casing cut level? 12a.Standing above the lop of castng7 16,Can cap be pulled loose? <br /> 3.Lid bolts missing? 9. febris In wellbox? 12b.Standing below the top of casing? 17.Can cap seal out water? <br /> 4.Lid 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? 14.Wellbox Is too far below grade? 13. Well cap present? iii.Padlock functional? <br /> 11.Wellbox Is crushedidamaged? 114. Well cap found secure? <br /> Check boX If no deficiencies were found. Nate below deficiencies you were able to correct. <br /> Well I.D. Deff clency Corrective Action Taken ' <br /> tJ%W-.1h <br /> i <br /> Note below all defiencles that could not be corrected and still treed to be corrected, ' <br /> BTS Office assigns or Date Date <br /> Well E.D. PersisUng Deficlenc defers Correctlon to: assigned corrected <br /> w 3 <br /> - 1375 70 <br /> . r � <br /> S <br />