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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client bO DO inspection Date <br /> [ l 0 Ve r3-iA►rrf ecc, C- . S.S <br /> Site Address _ _ _ Inspected By <br /> 1 Lid on box? 6 Casing secure? 12 water standing in wellbox? 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 wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lad 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 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secure? <br /> Check 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 stili need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br />