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WELLI.,-AD INSPECTION CHECKLIST AND REPAir-�ORDER <br /> C1tent Site# �-0� 7'SZV 1—r4 f Inspection date Q <br /> Site address . / � /✓ r' Inspected by <br /> 1 <br /> S p /V vt BTS Event# <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 /> t-1-1J-�---t 'T �n lAl�le•e•.�sn uiil{i 4nr�of tuGt�n�sr�7— '1(S-Q�rllne•♦t-fni enR TnnLe.f7__ _ <br /> 'Y LIU QUCLI II IL(%Vlk w •.uw. ,,.c..�i .rn.. .vj.. v. ...... vut.r v . u...vv.• wu.w wvF%. . I <br /> 6 Well caplpiug present? 11 Padlock functional? <br /> _ Check box if no dehclences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> yr <br /> Note below=allAdeficiences that=could=not-be=correctedpand-stilf=need-towbe=corrected <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to. assigned corrected <br /> i <br /> M <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s Y <br />