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an <br /> WELLHEAD INSPECTION CHECKLIST ANBD^ REPAIR <br /> /ORDE_R <br /> Client �i0 F - <br /> Site#2 O -75L4-Q3 il�� ' t lnspection date. " 1 <br /> Site address Z gr APF'1Ap�18y — <br /> � C j V1 ENVIRU1,BTS'Even4R,, <br /> pFM <br /> ' I Lid on the box? Yes No 5. Water standing in the well box? 7 Can cap be pulled loose? <br /> 2. Ldd whale? 5a. Standing above-well top?-- S=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 dericiences were found. Note below deficiencies you were able to correct <br /> ILDeficiency Corrective Action Taken <br /> I <br /> Note below all defictences that could not be corrected and stili need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLGHK.s <br />