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�T <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client r .c.L . Srle rr� 2ay 7 5 Z Y Inspection date- r) <br /> Site address v Inspected by941/ <br /> - <br /> �� ,U BTS Event# `16/I Z 5--i4/ <br /> I Lid on the box? Yes No 5. 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 water? <br /> 3 Lid secure? ab. Standing below well top? 9. Padlock present? <br /> 4 Lid seal intact? 5c. Water even Werth top of well cap? 10. Padlock found locked? <br /> 6. Well cap/plug present? 11. Padlock functional? <br /> Check box if no de sciences were found. Note below deficiencies you v.,ere able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> I <br /> tj <br /> I I <br /> I <br /> I <br /> I <br /> I <br />� I <br /> I <br /> I <br /> Mote below all deficiences that could not be corrected and still need to be corrected. <br /> STS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> I I <br /> I <br /> I <br /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s _ <br /> j J :� <br />