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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Cl,ent5aej.,�- Seen 7-0!y Z504Z410 S' Inspection date: I7�17-ciS <br /> Site address ).0 Inspected by. Jgt-/ <br /> S G BTS Event rt !95/227- /-/ <br /> I. Lid on the box? Yes No 5. Water slanoing 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 /> I Lid secure? 5b. Standing below well top? 9. Padlock present? <br /> 4. Lid seal intact? 5c. Water even with top of well cap? 10 Padlock found lockeo? <br /> 6 Well cap/plug present? 11 PGalock functional? <br /> Check box if no defrcrences were pound. Note below deficiencies you were able to correct <br /> Well f D. Deficiency Corrective Action Taken <br /> I i <br /> i <br /> i I <br /> I <br /> I I <br />� I i <br /> I <br /> I I <br /> Note below all deficiences that could nct be corrected and still need to be corrected <br /> BTS Office ass)gns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> I <br /> i <br /> I <br /> I <br /> I <br /> I I I <br /> i <br /> ONce review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />