Laserfiche WebLink
WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> iClcent Site#. � S?�f S Inspection date $—lam 'SIS <br /> Site address �o�A �J-�� Inspected by <br /> BTS Event 7 q5 OLls` Gi <br /> 1 Lid on the box? Yes No 5. Water standing in the well box-7 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 presents <br /> 4. Lid seal inta 7 Sc. Water even wdh top of well cap? 10 Padlock found locked? <br /> 6. Well cap/plug presents 11 Padlock functional? <br /> Check box if no deficrences were found. Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> Ik <br /> I <br /> i 1 <br /> l <br /> Note below all deficiences that could not be corrected and still need to be corrected. <br /> STS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Corrections to: assigned corrected <br /> IP <br /> Office review and assignments made by <br /> b � OL date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />