Laserfiche WebLink
�I J • �d <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client_�hC 1 1 -, Sde#2oAr''1 y Z4-Zku <br /> Inspectiondate I f 43 <br /> t4��- - �Q v S1�: v� � ---- 414 v L- -• <br /> -- ----- ----Site`address^-� � �� '�=- -Inspected by j;--'-- ---`-`-- - � <br /> <Ab( - - BTS Event# 9f30E712_' P' <br /> 1 Lid on the box? 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 top? 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 /> Check box if no deficiences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> l� <br /> Note_below-all Tdeficiences_that.cauid.not be-co rrected_and-still-need.to-be-corrected--- ----�_ -_ <br /> - —` - - --BTS Office assigns or - Date - Date -Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by - date <br /> Blaine Tern Se"--es, Inc. File WELLCHK s <br />