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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> s//1 <br /> ' Client 1 <br /> Site# Z��� Inspection date:44�� <br /> Site address ' Inspected by- <br /> 4`` _ BTS Event# �; <br /> 1 Lid on the box? Yes No S. Water standing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? Sa Standing above well top? 8 Can cap seal out waler? <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 ro defrclences were found. Note below deficiencies you were able to correct. <br /> Well 10. Deficiency Corrective Action Taken <br /> �✓CAS I ��� <br /> I <br /> I <br /> 1 <br /> f <br /> I <br /> Note below all def,c,ences that could not be corrected and st11l 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 dais <br /> Blaine Tech Services, Inc. File WELLCHK s <br />