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� w <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client 5�Gc. Site# `2-1-"/ - -7s-4-1- YV z Inspection date 7/F/9 7 <br /> Site address 2S75- V r-.-%.l Inspected by -7-(,- <br /> j <br /> rs-7-ci r-k- cx� BTS Event# 4 7c 7a 8-(--I <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 /> EfCheck box if no deficrences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> i <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 />