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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �;l%� e— _ Site OV 0a -:! of Inspection date 2 <br /> Site address 7S Coc-;,VZ CG Inspected by 47Z —_ <br /> ff [' BTS Event # �70a206'=f-/l <br /> 1 Lid on the box? Yes No 5 Water stancing in the well box? 7 Can cap be pulled loose? <br /> 2 Ltd whole? 5a Standing above well lop? 8 Can cap seal out wafer? <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal inlael? 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 defrcrences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> II I <br /> 1 I <br /> i I <br /> i I <br /> i <br /> I <br /> i <br /> Note below all deficiences that could not be corrected and st1I1 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 /> i <br /> i <br /> I <br /> I <br /> I <br /> i I <br /> Office review and assignments made by date <br /> Blame Tech Services, Inc File WELLCHK s <br />