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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client f�G Site# J "�/ Inspection date: <br /> Site address G' Inspected by v <br /> BTS Event# re!!�/ <br /> 1 Lid on the box? Yes No 5. Water standing in the well box? 7. Can cap be puffed 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? Sc. Water even with top of well cap? 10. Padlock found locked? <br /> S. Well cap/plug present? 11 Padlock functional? <br /> Check box if no deficlences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> i <br /> Note below all deficiences 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 corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />