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1 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client .1` _ Site#2Db--7 5$ -0eNO 1 Inspection date A-- 311 -C1 10\ _ -- <br /> 1d • Inspected b <br /> 3!l'� ��' c �� � Y <br /> Site address <br /> --Vv~�c <br /> STS Event# GC\ Dg3d <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's 10 Padlock found locked? <br /> 6 -Well cap/plug present? 11 Padlock functional? <br /> 12f Check box if no defrciences were found Note below deficiencses you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> Note below-ail deficience5-that- ouid ifat be corredted of d Ttil! meed 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 />