Laserfiche WebLink
WELL HEA© INSPECTION CHECKLIST AND REPAIR ORCER <br /> Cljent—S&141-zll� Sde# za 7 ©T4 Inspection date ! � <br /> Site address��lll� Lda�` ,�►,p,�l ,�/fd' 40 inspected by -- - If- ZE- - - - <br /> � r`Q� <br /> BTS Event# f0 <br /> 1 Lid on the boxy Yes No 5 Water standing 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 secure? 5b Standing below well tope 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 present? 11 Padlock functional? <br /> QCheck box it no deficrences were found. dote below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> I <br /> I <br /> I <br /> Note below all deficiencee that could not be corrected and sti11 need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> -Offl <br /> WAI Aw9Z6CI <br /> � I I <br /> I f � <br /> I <br /> I <br /> � ► i' <br /> Office review and assignments made by _____ date <br /> Blaine Tech Services, Inc File WELLCHK s <br />