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I ' <br /> F <br /> i WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER ` l" <br /> Client� etiJ� Sde# �� — $�� 101 Inspection date <br /> Site address 3-7 Z.5 -2-6--c-'Li ULU Q Inspected by <br /> c(f1 � BTS Event# qf06 <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*7 5a. Standing above well top? 8 Can cap seal out water's <br /> 3 Lid secures 5b. Standing below well top? 9 Padlock present? <br /> 4 Lid seal intactl 5c Water even with top of well cap? 10 Padlock found locked*2 <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deticiences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency <br /> Corrective Action Taken <br /> Note below all deficrences 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 Coirection to: - assigned- corrected <br /> f <br /> Office review and assignments made by date <br /> •} <br /> Blaine Tech Services, Inc File WELLCHK s <br />