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- t <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client 5nQ � Site# ZDy—j52,5- cioq Inspectiondate <br /> Site address (a 13( G LI¢7e, A ve Inspected by _ POJ6- <br /> CA. <br /> - <br /> CA. BTS Event# R 6o7�9 r 3 Z <br /> 1. Lid an 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? 56--Standing below well-toy? 9 Padldr-di present? <br /> 4 Lid seal intact? ac. 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 defccrences were found. Note below deficiencies you were able to correct <br /> Well E.D. Deficiency Corrective Action Taken <br /> T_ Note below-ail deficiences-that_could-not-be-corrected-and.stilL-need.to-be=corrected - --_ ---_ <br /> -- --- - - T ---- -_ - BTS Office assigns or -' _ -Date - ----Date- -- - - -- <br /> Weil I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> I I II i <br /> I� I <br /> Office review and assignments made by date <br /> niaine T X15 $esvice�, ilii, r=ile V11E._%.jr11 S <br />