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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site#;b 7s2Y—Y-?a1— Inspection date— S -V <br /> Site address Inspected by- Arr� <br /> BTS Event# 7''I <br /> 1 Lid on the box? Yes No 5Water 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 wrth top of well caps 10. Padlock found locked? <br /> 6 Well cap/plug present? 11. Padlock functional? <br /> Check box if no dellclences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all defciences 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 Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />