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I <br /> WELL, HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site r T l�L�r ,g Inspec3ion dater <br /> Site address j�co Ca/' Clab - Inspected by: <br /> A-, BTS Event# 7 �a Z <br /> I <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? 5a. Standing above well top? 8. Can cap seat 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 Pocked? <br /> - ' 6. , Well capiplug present? 11. Padlock functional? <br /> I <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 /> .5- 4, 1 A47 Ivck Pfct[( MN+d Z3S7 lec& ar. c � <br /> 5-F /10 &V yr lode- tf."d AVAI V1 CV 4" r fft/ 2357 Iaele 1 <br /> 5-1 /Ko i ad- etccd Nw& 2-357 f c.4. .,, '4 <br /> S-z NO lock.. � ,• ,� <br /> l <br /> -5-3 IV d r G7 It Cl94, 4 ,a N y <br /> 5 • iia f vck- <br /> f � <br /> a <br /> Note below all deficiences that could not be corrected and still need to be corrected. <br /> w <br /> - I <br /> t STS Office assigns or . Date ; . Date , <br /> Well I.D. Persisting Deficiency defers Correction to: assigned- corrected -- <br /> - <br /> T <br /> _ M I R,• I <br /> Office review and assignments made by ` T dale <br /> Blaine Tech Services, Pric. FileWELLCHK.s <br /> I <br />