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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> ClienSite# 7-57?4r/Sa9lnspectcondate: 8 -1-6 —� <br /> Site address 14) A/. Inspected by d-)+)!> 4�✓ rr2 <br /> GtC 'rpA/ . G BTS Event # C L 2 <br /> 1 Lid on the box? Yes No 5 Water stanc .ng in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing a`.y-ve well top? 8 Can cap seal out water'? <br /> 3 Lid secure? 5b. Standing be ow well top? 9 Padlock present? <br /> 4 Lid seal intact? Sc. Water even ,yrh top of well cap? 10 Padlock fosnd locked? <br /> 6 Well cap/plLO present? 11 Padlock functional? <br /> Check box if no deficrences were found. Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> I <br /> � I <br /> I <br /> I I <br /> I ' <br /> I <br /> i ! <br /> I I <br /> Note below all deficsences that could nct be corrected and still need to be corrected. <br /> i <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> -o& <br /> EQW- <br /> i' v3zf 15 7V o SM-t-& <br /> I <br /> f <br /> Office review and assignments made by 7M 6 date L3 <br /> Blame Tech Services, Inc. File WELLCHK s <br />