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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER JJ <br /> li <br /> Cl}ent Site# 001-- 75'Zy_35as' Inspection date i` Z —y8 <br /> Site address_ 2 75 Ca���r•� c I''',—^T Inspected by ak,- <br /> 54w,te 4a, 4 C4- BTS Event# ?Sol-Z-9-5 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 iop? 8 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? i i Padlock functional? <br /> ❑ Check box rf no deficiences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> lbw-3 Sam f3a,Ied ub4c - <br /> Il1W <br /> l7 Nr10 ►`4 ch? 4- Lock- <br /> Note <br /> ork-Note below all deficiences that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well LD Persisting Deficiency defers Correction to: assigned corrected <br /> E - <br /> i <br /> Office review and assignments made by date <br /> r <br /> Blaine Tech Services, Inc File WELLCHK s <br />