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n WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER T, „ a „ <br /> Client -eJt Site# 'zv4 7S Z�f 3p S Inspection date Z t 910 <br /> Site address �ZO Gc.� `` '� �.1J Inspected by. . C-1 , - <br /> 54 / BTS Event# IT RDS ze --G! . <br /> 1 Lid on the box? Yes No 5 Water standing to 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 /> .3.1id 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 present2 11 Padlock fvnctionall <br /> Check box if no defrcrences 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 /> I <br /> Office review and assignments made by date • <br /> Blaine Tech Services, Inc Fie WELLCHK s <br />