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i <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Chent_4 t� Site#Z' -[`15 7,4 - OZ.Qt,( Inspection date <br /> Site address vw,,Av d- Inspected by IMiILI- S. <br /> Ca ` BTS Event# cLo!O$ <br /> 1 Lid on the box? Yes No 5 Water standing to 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? 15c 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 defictences were found Note below deficiencies you were able to correct <br /> Weli I.D. Deficiency Corrective Action Taken <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well 1.13 Persisting Deficiency defers Correction to- assigned corrected <br /> _Z <br /> Office review and assignments made b �t 11v �Z <br /> 9 Y t t ' date <br /> Blame Tech Services, Inc File WELLCHK s <br />