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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client ire Sde#_ Zo� �S Z� �13� Inspection date Z L <br /> Site address Za W dto(k r Inspected by <br /> 4oGk401-7 G BTS Event <br /> 1 Lid on the box? Yes No 5 Water stanoing in the well box? 7 Can cap be pulp loose? <br /> 2 Lid whole? 5a Stanoing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b Standing bellow well top? 9. Padlock present? <br /> 4 Lid seal intact? 5c Water even v rih top of well cap? 10 Paolock found loclked? <br /> 6 Well caplplug present? 11 Paolock functional? <br /> Check box if no defrcrences were found. Note belov; deficiencies you veere able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> f <br /> I� <br /> 1 <br /> f I <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> BTS Df;ice assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> I f <br /> f <br /> f <br /> 1 <br /> 1 <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />