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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Y7 O1 f 1 <br /> Gliena— SI* <br /> Z0 a90 Inspectllate: 5 <br /> Site address Z� 9� Inspected by- <br /> • —IXT BTS Event# �6 0 <br /> 1 Lid on the box'2 Yes No 5. Water standing in the well box? 7 Can cap be pulled looser <br /> 2. Lid whole? 5a. Standing above well top? 8. Can cap seal out water's <br /> 3 Lid securer 5b. Standing below well top? 9. Padlock present? <br /> 4. Lid seal intactl 5c. Water even with top of well cap? 10 Padlock found locked; <br /> 6 Well calx/plug present'? _ 11 Padlock functionai; <br /> Check box if no deficrences were found. Note beew deficiencies you were aole to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> 0 <br /> 'erWFGG t � <br /> -C//I�G77 zff- Z 3 5-7 L0 e k <br /> • <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 /> C <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. Rle WELLCHK.s <br />