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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client 57IJ04L S d e# 2 0 SDS Inspection date!V <br /> Site address 721 b L v wF.e Inspected by 4A-l> l3 O[-✓tri <br /> S7aG,�7pill Ctl BTS Event# 140f3/6 f L1 <br /> 1 Lid on the box? Yes No 5 Water standing in the weil box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing above weii top? 8 Can cap seal out water <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present'? <br /> 4 Lid seal intact? Sc Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functionai? <br /> F7 Check box if no defrcrences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> vv eA> o-r I-vlial oAM-L iii 'qJA e jq p <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 Corrections to: assigned corrected <br /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />