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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER " <br /> Client <br /> Sh-ei l Site# 2.C74" 35a5, Inspection date LI-7-3 -18 <br /> Site address. 2.575- Cou.A4,,j C l vb Inspected by POV(r fi ✓"ATT <br /> d <br /> S�k`� , c� __ BTS Event# 95-0q7-3-S I <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 =Lid secure? 5b.Standing below—well lop? 9 _P_adlock 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? <br /> ® Check box if no derrciences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> i <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 /> Office review and assignments made b_n/W LAW M V4L V date . <br /> Blaine Tech Services, Inc File WELLCHK s <br />