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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client�f�z''�� Site Inspection date <br /> Site ad ress�7� r_ 6 Inspected by <br /> BTS Event# <br /> 1 Lid on the box2 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 present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug presents 11 Padlock functional? <br /> ivcheck box if no def fences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> f <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 /> c.✓ 1 <br /> • Office review and assignments made by date <br /> Blaine Tech Services, Inc F=ile WELLCHK s <br />