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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> 1 <br /> Client Site# ZD��- 7 S`2 t/- 5 0 Inspection date:_ <br /> Site address Z 97Inspected by: ' <br /> BTS.Event# r R 0 12 7—,1 l A <br /> 1. Lid on the box? Yes No S. 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 ca"lug present? 11. Padlock functional? <br /> Check box if no defrciences were found. Note below deficiencies you were able to correct <br /> F , <br /> f Welt I.D. Deficiency Corrective Action Taken <br /> G <br /> "e <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 /> IL <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHKs <br />