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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client. � f/ LC, 2� <br /> Inspection date. Z <br /> Site address AVAIr Sl Inspected by <br /> rik X/ <br /> BTS Event# <br /> F <br /> Lad onthe box? Yes No 5 Water standing in the well box? 7 Can cap be pulled Icose,Lad whole-7 5a. Standing above well top 8. Can cap seal out waters <br /> Lad secure'? 5b. Standing below well tap? 9 Padlock present'? <br /> 4. Vd seal mt=,2 15c- Water even with top of well <br /> cap 10 Padlock found locked? <br /> ll caplplug present-7 11 Padlock functional? <br /> j! <br /> �eck�box �nocta�fician�cswere found. Note below deficiencies you were able to correct. <br /> Well I.D. Defic:ency Corrective Actions Taken <br /> I <br /> !!I <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> Wel[ I.D. Persistirs Deficiency BTS Office assigns or Date Date <br /> S cy defers Correction to: assigned corrected <br /> FT <br /> I <br /> r <br />� I I <br /> • Office review and assignments ig meats made by date <br /> Blmne Tech Services, Inc. Fie WEii CH{.s <br />