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i 1 <br /> f � <br /> � <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER �1 <br /> Client Site# Ccs2S C y0<�'e76 Inspection date <br /> Site address_ _ � �i/�I�P�(1��4.-r Y Inspected by / <br /> 5 BTS Event# <br /> 1 Lid on the box2 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 /> heck box if no defrcrences were found Note below deficiencies you were able to correct <br /> Well 1 D. Deficiency Corrective Action Taken <br /> • <br /> Note-below-all-deficrences that could not be corrected and stiff need to be corrected <br /> ate <br /> Well I D Persisting Deficiency <br /> BTS <br /> e ers Correction to:ns assigned Date corrected <br /> s <br /> FI- <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />