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00 WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �'t L L Srie# 24'V-7-'5.-2 -Zgoo Inspection date 90:2 2S <br /> Site address qo/6- I-L � Inspected by Jl <br /> BTS Evert <br /> 1 Lid on the box? Yes No 5 Water staneing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing above well top? 8 Can cap seal out v;ater? <br /> 3 Lid secure? 5b Stancing belc,,r well top? 9 Paclock present? <br /> 4 Lid seal intact? Sc Water even with lop of well cap? 10 Padlock found locked? <br /> o" Well caplplug present? 11 Padlock functional? <br /> ❑ Check box if no deficiences v;ere found Note belove deficiencies you 1-.,ere able to Correct <br /> Well I D. Deficiency Corrective Action Taken <br /> I I <br /> f I <br /> I - <br /> I <br /> I <br />� I I <br /> I <br /> I <br /> Note below ad deficiences that could net be corrected and sill need ;o be ccrrecred <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to. assigned corrected <br /> 1 I I <br /> I I I <br /> I I I <br /> I I <br /> I I <br /> 1 <br /> I I <br /> I <br /> I <br /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />