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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Ment Sde# -775-2-1�r IM�' Inspection date 75 <br /> Site address 2 Inspected by <br /> S� BTS Event# <br /> 1 Lid on the box? Yes No 5 Water standing in the well box2 7 Can cap be pulled loose9 <br /> 2 Lid whole? Sa Standing above well top? S Can cap seal out water? <br /> 3 Lid secure9 5b. Standing below well top? 9 Padlock present <br /> 4 Lid seal intact? 5c. Water even with top of well cape 10 Padlock found locked2 <br /> 6 Well cap/plug present's 1 11 Padlock functional' <br /> ❑ Check box if no dericiences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> —L5 Z er <br /> Y <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 /> 61 NS G- <br /> z ja <br /> v <br /> Office review and assignments made by7P'----date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />