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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client 5 ',l Site -," o �`���Z�� I SZ)ci Inspection date / /S <br /> Site address f yl ' " ` r Inspected by /�C <br /> BTS Event <br /> 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? Sa 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 lockea? <br /> 6 Well 9P <br /> caP/p lu resent? 11 Padlock functional? <br /> Check box if no deficrences were found Note below defic,encies you were able to correct. <br /> Well I D Deficiency Corrective Action Taken <br /> I <br /> I <br /> I I <br /> ! I <br /> I <br /> ! I <br /> Note below all deficrences 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 /> v� v� <br /> ! <br /> ! I <br /> ! I <br /> I <br /> Office review and assignments made by _ t—, J c _iTi date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />