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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client ��t"V Site# 2 0� �SZ�'43a� Inspection date <br /> Site address &Z O W, C kG rbc f W&• Inspected by <br /> !j-roc k'-0 -\ BTS Event# <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 cut 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 defrctences were found Note below deficiencies 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 to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency deters Correction to assigned corrected <br /> L 1 <br /> Office review ono assrcnmF7,c Tac v date <br /> -rc , '-vices, Inc Re WELLCI1K s <br />