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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client..2 PF-LC- Sde# 75 Z S 0/05/ Inspection date )1- z 6 - FC <br /> Site address 6/31 64e iG is �' � Inspected by /2U <br /> alk-roti BTS Event# 96//z� -a� <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 wish top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> heck box if no deficiences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <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 Y <br /> assignments made b date <br /> g <br /> Blaine Tech Services, Inc. File WELI_CHK s <br /> I <br />