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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client l Site# ZU�k` 52- 13 0-7 Inspection date: 2 y <br /> - , <br /> Site address -1 � Inspected by"' � y <br /> t STS Event# 043 l 2" ?Z <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 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 /> Check box if no deficiences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> i <br /> i <br /> Note below all deficiences 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 i <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />