Laserfiche WebLink
WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER , <br /> Client Site# 2�_e( S�y fdD6 <br /> Inspection date <br /> r{�`{ T�d��r J7 7— Inspected by _ � <br /> Site address <br /> BTS Event# <br /> i <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 capiplug present? 11 Padlock functional? <br /> r <br /> n—Check box if no defrciences were found Note below deficiencies you were able to correct <br /> Well I.D. Deficiency f' 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 LD Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />