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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client � 5de#. inspection date: <br /> Site addressUAVInspected by: <br /> BTS Event# <br /> [I. Lidonlhet>ox? Yes No S. Water standing in the well box? 7. Can cap be pulled looses <br /> 2 Lid whole? 5a.Standing above well top? 8. Can cap seal out water? <br /> 3. Lid secure? 5b. Standing below well lop? 9. Padlock present? <br /> 4. Lid seal intact? 5c. Water even wdh top of well cap? 10. Padlock found locked? <br /> 6. Well cap/plug present? 11. Padlock functional? <br /> Check box if no deAciences were found. Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> Iv <br /> I <br /> Mote below all deficiences that could not be corrected and strll 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 b <br /> 9 Y date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />