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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client &-k - _ Site# 20Lt --?SIli-LihP Inspection date <br /> Site address C,24D W Inspected by F <br /> S-r6 «- BTS Event# Bo Zsrk--A I <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 sea!out water? <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 /> S 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 Taken <br /> Note below all deflciences that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> �1 <br /> Office review and assignments made by I date <br /> Blaine Tech Services, Inc Fife WELLCHK.s <br />