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WR L HEAD INSPECTION CHECKUST AND REPAIR ORDER! <br /> Client : exa c-e __ Site# C z S C qO Z 7 6 Inspection date: y r/ <br /> Site address 61yo V`'` C_ U r W Inspected b <br /> --- _ ;Acc-�� CA- - BTS Event# '781( of 1 <br /> 1. Lid on the box? Yes No S Water standing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole) 5a. Standing above well top'7 8 Can cap seal out water? <br /> 3 Lad 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 /> R/Check box if no deficrences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> 1 <br /> 4 <br /> �a <br /> I <br /> =Note below all de#iciences 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 Cotmection to: assigned corrected <br /> .3 <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELL.CHK.s <br />