Laserfiche WebLink
WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client • 5F44 Site# Zv Inspection date 1©kvl 9 <br /> Site address 2S Z�- 6-X-'LL4,, , C I L4 6 Inspected by �/►��- _ <br /> -- If . C& BTS Event# b Lo U 6 - j <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing above well top? 8 Can cap seal out water? <br /> =3-L=id secure? Sb=Standing below-we-11-tap? 5—Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional'2 <br /> heck box if no defictences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Takers <br /> 4 <br /> r <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 /> IF 7 <br /> Office review and assignments made by date • <br /> Blaine Tech Services, Inc File WELLCHK s <br />