Laserfiche WebLink
WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Side T _2)x/7 7 -2PI0K-/Inspection date: 1� S <br /> Sile address U l3 A-C;T � AL, Inspected by: G <br /> BTS Event z t�sff��flf <br /> 1 Lid on the box? Yes No S. Water slancing 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 seoire? Sb Standina below well top? 9. Padlock present? <br /> 4 Lids intact? Sr. %l�a'er even with top of%yell cap? 10 Paclock found loc' ea? <br /> 6 l'i'ef! cap'p!ug present? 11. Paolo:k functional? <br /> Check box if no deficrences were fcund Nolle below deficienc,es you were able to correct. <br /> VIlell I D. Deficiency Corrective Action Taken <br /> f <br /> I I <br /> I <br /> I i <br /> I <br /> I I <br /> I I <br />� I I <br /> I I <br /> I 1 <br /> mote below Gil ceficierice s that could not be corrected and st111 reed to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> I I <br /> ij <br /> I I <br /> I <br /> � I <br /> +I <br /> I I <br /> I <br /> OYce review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />