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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# IDA—IDA--1Sx4-3,0 f Inspection date -7 I-2--71 � <br /> Site address zSr S Girh Inspected by <br /> Cl,� <br /> pG� CPr 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-above--well 8 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 deflclences were found Note below deficiencies you were able to correct <br /> Well I.D Deficiency Corrective Action Taken <br /> wL a o � • <br /> i 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 /> - - - - r CA I - - - -- <br /> I <br /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />