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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Site � � �`7 Inspection date <br /> CGeniell <br /> Site address Gr� Inspected by <br /> BTS EventA0 <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? Sa. 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? Sc Water even with top of well cap? 10. Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deficiences were found. Note below deficiencies you were able to correct. <br /> Well 10. Deficiency Correcti a Action Taken <br /> AV <br /> I <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> STS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. Fie WELLCHK.s <br />