Laserfiche WebLink
WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client„ Site# Zo l SV q Inspection date 11-14 -q:! <br /> Site address Al FZ- t�v"J>0 s7' Inspected by GA-1>— oL i6fZ' <br /> ,_S7'-pC`TTor�, C BTS Event#5?- /�'!LZ <br /> I 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 Padlock present? <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 /> i <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 by dale <br /> Blaine Tech Services, Inc Fie WELLCHK.s <br />