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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client X7524-' 05 Inspection date_ I I+ � <br /> ghell W ,.aTER <br /> Site address fi2fl Vt. ON Inspected by �'Cs <br /> S7OCICY.� <br /> C. <br /> BTS Event#I` <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 tops -8--Can-cap-seal out.water <br /> 3 Ltd secure? 5b Standing Below well tope 9 Padlock present's <br /> 4 Lid seal intact? 5c Water even wdh 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 /> 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 Seances, Inc File WELLCHK s <br />