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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# Inspection date* /G g <br /> Site address, /64/ /V �L (�o7e_ Inspected by <br /> BTS Event# ��O /D Z- <br /> 1 <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? 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 cap/plug present? 11 Padlock functional? <br /> Check box if no deficiences were found. Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> SfJ- h GY l ledj <br /> D <br /> Note below all defciences that could not be corrected and sty!l need to be corrected. <br /> BTS 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 />