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OCT 416' 98 (FRI) 15 25 BLAINE TECH SERVICES, 1NC TEL 408 513 1111 P 012 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Q <br /> Client Wr k Site# Inspection date <br /> Site address. coo 61 aw Inspected by S <br /> -rrA BTS Event tr O R_Z 9 .I <br /> 1 Lod 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 it no defcrences were found Note below deficiencies you were able to correct <br /> Well I.D. DeflclencV Carreative Action Taken <br /> Note below all deficlences that could not be corrected and still need to be corrected <br /> BTS Office WIgns or Date Date <br /> Well I.D. Persisting Daliclency defers CormctIon to: assigned corrected <br /> Ell <br /> Office review and assignments made by date <br /> Slaine Tech Services, Inc File WELLCHK s <br />