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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client L Site# 2441 `fir2 U ? Inspection dale: <br /> Site addres 4 5'- LFX al'V4G A& Inspected by- <br /> S zK-1011) , .4 BTS Event# JW <br /> 3 <br /> 1 Lid on the box? Yes No 5. Water stanaing 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 top? 9. Padlock present? <br /> 4 Lid seal intact? Sc. Water even with top of well cap's 10. Padlock found locked? <br /> 6. Well cap/plug present? 11. Padlock functional) <br /> 12/Check box if no deficlences were found. Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> I <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 /> K <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />