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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER f <br /> Cbent_ LA I _ Site# - 15A-35 15 Inspection date 7��1Z ! / <br /> Site address �S 2 C"4�-it` i ) Inspected by � _ <br /> t BTS Evenl # elq/G'-�O -ry <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled Inose? <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? Sc Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 1 i Padlock functional? <br /> Check box if no defrciences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> i <br /> Note below all deflclences 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 /> � � II <br /> '1 y <br /> VAX <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />