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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Ghent SELL Site Inspection date 7-Iz9-9g <br /> Site address 7-S75-- Covsr �C�6 Inspected by <br /> 54w,k4o., , G4+ BTS Event# <br /> 1 Lid on the boxy Yes No 5 Water standing in the well box? 7 Can cap be pulled loose'? <br /> 2 Lid whole's 5a Standing above well top'2 8 Can cap seat out water9 <br /> -3:L-!d sesure25b-Standing below well tope 9 =�Padlack present <br /> 4 Lid seal intact? Sc. Water even with top of well cap? 10 Padlock found locked'2 <br /> 6 Weil cap/plug present? f 1 Padlock functional) <br /> Check box if no deficiences were found. Note below deficiencies you were able to correct <br /> Weil I.D. Deficiency Corrective Action Taken <br /> Note below all deficiences 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 /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK.s <br />