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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client ` 7 � Inspection date <br /> Site address '7-5-?S- Ce u^/ Y' Cr Inspected by <br /> JAG csCr-v-.r , C"-4 BTS Event# 97f�-�- <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 seal 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 /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no defrcrences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> i <br /> �✓ -/ mac' C C CAL <br /> r <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 /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />