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.r <br /> WEEL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client ���[� Site# 26 S� 7 ���� Inspection date ,L <br /> Site address <br /> Inspected by <br /> BTS Event# <br /> Y Ld on the box? Yes No 5. Water standing in the-well box? 7-Can cap be pulled loose <br /> 2 Lid whole'2 Sa. Standing above well 1op'7 S. Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well tops 19 Padlock present? <br /> 4 Lid seal intact _ - _ 5c.-Water-even with top of-well cape--10-Padlock found locked? <br /> 6. Well can/plug present? 11 Padlock functional? <br /> �heck box if no defi6ences were found. Note below defic:enc:es you were able to correct <br /> A Vell I.D. Defic:ency Corrective Action Taken <br /> 7 41 <br /> f <br /> r <br /> Note below a!i defiaences_that could not be-corrected and-still-need to-be-corrected <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Defia:ency defers Correction to: assigned corrected <br /> Offic-- review and ass:gnmantg m de k.&JY date <br /> Blaine Tech Services, Inc. Fie WELLCHK.s <br />