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f' <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER r " <br /> ZD�--75Zq- f5bg 1, <br /> Client S 4 Site# Inspection date <br /> Site address Jqj .1,/ pb mdo Inspected by- TbUG– <br /> syA-64 � A BTS Event# f O7Zj�--S / <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-7 8 Can cap seal out water's <br /> =3- Lid secure? 5b:Standing below-well top? 9=Padlock-present <br /> 4. Lid seal intact? 5c. Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well captplug present? 11 Padlock functional? <br /> Check box if no deficiencss 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 st11I need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency deters Correction to: assigned carrected <br /> II� <br /> i <br /> r , <br /> F � <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc Fie WELLCHK.s <br /> 1. <br />