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WELLHE INSPECTION CHECKLIST AND .PAIR ORDER <br /> Client A rC a Inspection Date 6 - 17"4 <br /> is Site Address y �� Tr �,,. -Fr- !%t Inspected By� 13 rd•4/ <br /> 1 Lid on box? 6 Casing secure? 112 Water standing in welibox? 15 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? 8 Debris in wellbox7 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? 10 Well box is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushedldamaged? 14 Well cap found secure? <br /> GQCheck box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <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 />