Laserfiche WebLink
I <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S-1-kA Site# Z() `�` 7� u- a q 01 Inspection date Il I Z Kl9t3 <br /> Site address -7 ZS �� Trac3�-cr inspected by S • <br /> BTS Event# 11 z — �3 <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 defictences were found Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> M 4J-3 I 6,-kj,-, 1,,h I�z� Gj/ 23 S'7 <br /> MLJ-L 13rolLe,, Cc if <br /> -- — --- --Note-below all ddfidiences that could nof6e corrected and still need-to-Ne corrected <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> EE <br /> ZZU <br /> i� <br /> Office review and assignments made by date <br /> Blaine Tecn Services, Inc Fie WELLCHK s <br />