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e <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S ELG Sae dam' 755- - o� Inspection date �0 <br /> Site address �GY � Inspected by <br /> �jf Gya BTS Event# <br /> 1 Lid on the box? Yes No 5 Water stanaing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? Sa Standing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well lop? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 8 Well cap/plug present? 11 Padlock functional? <br /> ❑ Check box if no deficrences v<!ere found Note below deficiencies you were able to correct <br /> Well I D Deficiency ff Gorrective Action Taken <br /> r ' <br /> Lfrv- / <br /> (✓r w <br /> I <br /> 1 <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 /> I <br /> • <br /> Office review and assignments made by date <br /> Blame Tech Services, Inc File WELLCHK s <br />