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ti <br /> , nn WELL HEAD INSPECnCN CHECKLIST AND REPAIR ORDER <br /> Client <!LCS� Site# 24q-7SZ y- SSD j Inspection date: 1/1/Z6 <br /> Site address /L/I iv- / D6 Inspected by: 5_L+ <br /> '9_+OG7C4 C!$-- _ ETS Event# 99 QI Z C -Tz <br /> 1. Lid on the box? Yes No 5 Water standing in the we#1 box? 7._C4n cap be pulled loose. <br /> — <br /> 2. Lid whole? 5a. Standing above well tcp,2 8. Can cap seal out waren - <br /> 3. Lid secure? 5b. Standing below well top? 9. Padlock presenr7 <br /> 4. Lid seal intact? 5c. Water even with top of well cep? 10. Padlock found locked? <br /> 6. Weff a p/plug present? 11. Padlodc functional? <br /> Check box d no deficiences were found. Norte below defi=e=es you were able to correct. <br /> Well LD. Deficiency Coniective Action Taken <br /> f <br /> Note below all deficiences that could not be carrected and sfii/need to be corrected <br /> STS-Office assigns or Date Date <br /> Well I.D. Persisting Defimency defers Correction to: assigned corrected <br /> F1 <br /> f <br /> s� <br /> Cffice review and assignments made by date <br /> Blaine Tech Services, Inc. File WE I CHK_s <br />