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1 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Mi Z- S d e#- -2-0 V or Inspection date -2 <br /> Site address -2-C) c-, G�r`�27ra Inspected by- <br /> -f;;-CJ <br /> y•-fyCJ C-.0 77e-� - �� BTS Event# <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? Sc. Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deficiences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Takers <br /> Note below all deficlences that could not be corrected and stili need to be corrected. <br /> s <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected s <br /> r <br /> Office review and assignments made by dale l <br /> Blaine Tech Services, Inc. File WELLCHK s <br />