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A <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client_! � t/. e— Site# Z --7T 2_ --1su? Inspection date: Icr5 5 R <br /> Site address b`f IV Inspected '1Arf — <br /> �l <br /> — r tied ry: y <br /> BTSEvent#_ y9lor �— � Z <br /> 1. Lid on the box? Yes No 5. Water standing in the well box? 7. Can cap be pulled loose? <br /> =2:L--id--whole? 5a:Standing°above=weli`top? ,B-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? Ill 1. Padlock functional? <br /> ❑ Check box if no deficiences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all defciences 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 /> _W-i e N�tiJ l:ML L t�� <br /> r S <br /> Ale-4s l " Lc� <br /> �." tla I•� L�rtz,� <br /> Office review and assignments made by Bate <br /> Blaine Tech Services, Inc. 7iie WE'- <br />