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• ` WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client 5�yezll' Site#c2041'?5:;L`f—Zsj. Inspection date, <br /> Site address C_O inspected by <br /> aw2-Az 64- BTS Event#20712-1/ <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 /> fi. Well cap/plug present? 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 /> 1 <br /> i� <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 I.D. Persisting Deficiency defers Correction to; assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />