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i <br />WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br />Citern Site #Z.oK-77 yJoS Inspection date: <br />Site address t9 ZO L,J. Ll-6der 4/ Inspected by J 2 <br />BTS Event #_ -?Og i S X-1 0 <br />1. Lid on the box? Yes No 5 Water standing in the well boxy 7 Can cap be pulled looser <br />2. Ltd whole? 5a Standing -above -well tops 8._Can cap seal out=water? <br />3. Lid securer 5b Standing below well tops 9 Padlock presents <br />4 Ltd seal tntact2 15C. Water even with top of well cap's 10 Padlock found locked? <br />6 Well cap/plug present? 11. Padlock functional? <br />Check box if no deFclences were found. Note below deficiencies you were able to correct <br />Well I.D. Deficiency Corrective Action Taken <br />Note below all deficiences that could not be corrected and still need to be corrected. <br />Well l_D_ PaMiefinry n,&4;-.---. <br />Cffice review and assignments made by <br />BTS Office assigns or Date Date <br />defers Correction to: assigned corrected <br />Blaine Tech Services, Inc Fie WELLCHK.s <br />date <br />• <br />