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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �i Sste � Z¢ 3 Inspc-coon dae <br /> Site address 06,03. fit-VA Inspected by <br /> S�d�trV BTS Event # �7/�e��—L/ <br /> I Lid on the box? Yes No 5 Water standing in the yell box? 7 Can cap be puffed loose? <br /> =2=Lqd=whole? 5a-S1anding=above=well top? 8--Gan cap seal out-%nater? <br /> 3 Lid secure? 5b Standing below well top? 9 Pcolock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found lockea? <br /> 6 Well cap/plug present? 11. Padlock functional? <br /> Check box if no deficiences vrere found Note below deficiencies you were able to correct <br /> is Well I D Deficiency Corrective Action Taken <br /> 1t+ -P 1 f <br /> Note below all deficlences that could not be correcfed and sirll need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well 1 D. Persisting Deficiency defers Correction to, assfgne-t corrected <br /> I <br /> Office review and assignmenis made by date <br /> Blaine Tech Services, Inc. File WE. s <br />