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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �� 0 Site 7(o Inspection date <br /> Site address 4A-0 kZ . Ctn�.r � Inspected by <br /> �='Iltv t`r-tel 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? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> tellD <br /> ck box if no deficrences were found Note below deficiencies you were able to correct <br /> Deficiency Corrective Action Taken <br /> I <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 1.13 Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK.s <br /> a <br />