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r' <br /> WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> CIlent '�-1 1",QA Site# ZO"1 - 1-7,�Z - 13 0 7 Inspection date_ j t 0 /99 <br /> Site address 12 7 Cam �r C�+� _ Inspected by S !V� <br /> _ t <br /> S4ocK�,._. C , _ „ BTS Event# �8�1l� -S l <br /> 1 Ltd on the box? Yes No 5 Water standing in the well box*7 7 Can cap be pulled loose) <br /> =2-Lid-whole? 5a Standjng above well tops 8=Can-cap seal-out water <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present <br /> 4 Lid seal intactl 5c. Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present7 11 Padlock functional? <br /> heck box if no defrciences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> �l <br /> Note below all defictences 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 's <br /> Blaine Tech Services, Inc. Fie WELLCHK s <br />