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r <br />WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br />Client s Sde # zy Inspection date.//A7 <br />. Site address Inspected by <br />BTS Event # <br />Y Lid on the box? Yes <br />No <br />5 <br />Water standing in the well box? <br />7 <br />Can cap be pulled loose? <br />2 Lid whole? <br />5a <br />Standing above well top? <br />8. <br />Can cap seal out water? <br />3 Lid secure? <br />5b. <br />Standing below well top? <br />9. <br />Padlock present? <br />4 Lid seal intact? <br />Sc <br />Water even with top of well cap? <br />10 <br />Padlock found locked? <br />6 <br />Well cap/plug present? <br />11 <br />Padlock functional? <br />heck box if no deficiences were found <br />Note below deficiencies you were able to correct <br />Well I D. Deficiency Corrective Action Taken <br />Note below all deficiences that could not be corrected and still need to be corrected <br />Wall 1 n_ Persistina Deficiencv <br />BTS Office assigns or Date Date <br />defers Correction to: assigned corrected <br />Office review and assignments made by <br />Blame Tech Services, Inc File WELLCHK s <br />date <br />