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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S CO- Site# -007-5Z -) 2/06 Inspection date <br /> Site address Zlgq PF4!;X/N 6 Inspected by 12, <br /> G✓-rc>c—K'-ro nJ BTS Event# <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? 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 Corrective Action Taken <br /> 4� <br /> f <br /> C <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 /> 1 <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />