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WELLNE INSPECTION CHECKLIST AND f ,-'AIR ORDER <br /> Client kGC)Z0 Inspection Date '1 4"Z <br /> We Address 1"? G, �f N, Inspected By Jai 1t't-+ <br /> O a_.9a•t <br /> 1 Lid on box? 6 Casing secure? 12 Water standing In wellbox? 15 Well cap functional? <br /> 2.Lid broken? 7 Casing out level? 12a Standing above the top of casing7 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 stnpped7 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock presenl7 <br /> 5 Lid seal Intact? 10 Wellbox is too for below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wegbox Is crushed/damaged? 14 Well cap found secure? <br /> IXCheck box If no deficiencies were found Note below deficiencies you were able to correct. <br /> Well I_D Deficiency Corrective Action Taken <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well i D Persistln Deficlenc defers Correction to asst red corrected <br />