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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Q-L— Site# ZDy -7152)4 3 Sam Inspection date <br /> Site address ZS-7S CouN F" C )- 6 Inspected by T- <br /> 4 <br /> 4 1 D c.e—TD N BTS Event# q Sy 1 ZY --G <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? S Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? Sc 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 deficlences were found Note below deficiencies you were able to correct <br /> Well E.D. Deficiency Corrective Action Taken <br /> w Z tv0 L_0c <br /> _ Mw3 <br /> w � <br /> Note below all deficiences that could not be corrected and still need to be corrected. <br /> STS 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 />