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T <br /> - 1► .1 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S)jf=Lt t-- Site# 2-A4-76.Z4 -/S Inspection date. 7 Z(p <br /> Site address Inspected by-_ ` <br /> -% .- <br /> STS Event 4F -moi �' —1 2 <br /> Z Lid on the box'7 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*2 <br /> 4 Lid seal intactl 5c Water even with top of well cap? 10. Padlock found iockedl <br /> S. Well cap/plug present? 11 Padlock functional? <br /> Check box if no deftcrences were found. Note below deficiencies you were able to correct. <br /> Well I.D_ Deficiency Corrective Action Taken <br /> FLO Z I G CAP { .SA{► 6- 1v76�s <br /> �''� <br /> No W, Ltd �0 `u us I 1��� 2 7 sn cw►,� <br /> I i <br /> I I <br /> Note below all defrciences 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 carrected <br /> 2ab I <br /> I <br /> I <br /> � I <br /> I I f <br /> I <br /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />