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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER . <br /> Client Site# �-+�y'`�s�-" �� Inspection date: 5`���M-A-4 <br /> Site address `�..�� G� �-��� Inspected by: � . <br /> 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 alcove well top? 8. Can cap sea[out water? <br /> 3. Lid secure? 5b. Standing below well top? 9. Padlock present? <br /> 4. Lid sea] 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 aide to correct. <br /> Well I.D. Deficiency Corrective Action Taken <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 /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. Flb WELLCHK.s <br />