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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Clierrn'4-t 11 Site# -�– �-CiZG� 1 Inspection date <br /> Site address 3� �'S - S Inspected by f-' /, it <br /> BTS Event#, 2)0 <br /> 1 Ltd on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose? <br /> 2_ Ltd whole? 5a Standing above well tap? 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 2 10 Padlock found locked? <br /> --6 Well cap/plug present? 11 Padlock functional? <br /> Nrcheck <br /> box if nn deficiences were found. Note below deficienc:es you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> _Note_below-all_deflciences-that could-not_be-corrected-and-still-need fo-be.corrected.--- – – — <br /> -BTS Office assigns or - Date - - Date <br /> Well LD. Persisting Deficiency defers Correction to: assigned corrected <br /> l� <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />