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WELLHEAD - L <br /> INSPECTIONICHECKLIST AND REPAIR ORDER <br /> � <br /> Client i Site# ;��"I`q'lL `' qW Inspection date 0 f <br /> i`I f Inspected to �►' � <br /> Site address �/I ( � r p Y' <br /> BTS EventSO L <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 defrciences were found. Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> m wll T o ut <br /> PAW-3 <br /> V - <br /> k <br /> f f <br /> f II <br /> I <br /> Note below all defciences 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 />