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' iai al,a t <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S _Sde# Z04-75-75' -O(cD y Inspection date <br /> Site address el f PQ�� Ati 62d inspected by S+dyc <br /> s K BTS Event# � 3 J / <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 top? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present2 11 Padlock functional? <br /> heck box if no defrcrences were found Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> --_Note below all_deficiences that`couId_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 /> f , <br /> Office review and assignments made by date <br /> Elaine Tech Services Inc Fie WELLCI-,< s <br />