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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S ,�� Site# ZDV 1152 13oZ Inspection date 9�osa6-x� <br /> Site address 1 Z6 inspected by i!!, <br /> C k t c2(3 - BTS Event# <br /> i s L-id on the box?Yes�No= 5.—Water standing in the-well boxy= 7—_Can cap be pulled loose <br /> 2 Lid whole? 5a. Standing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b. Standing below well top? 9 Padlock presents <br /> 4 Lid seal intact? 5c. Water even with top of well cap? 14 Padlock found locked? <br /> 6 Well cap/plug present? 11. Padlock functional? <br /> ❑ Check box if no deficiences were found. 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 /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> s� <br /> '0' �ru <br /> s"1 r c -c <br /> S- <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK.s <br />