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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client_ Site# Inspection date :Z/947 <br /> Site address— l y�__---� c •mac�,4 Jc Inspected by 7 <br /> -t 7-0 4k yam✓ BTS Event# c/-70 70 ri -_r- <br /> [ <br /> F <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 Pocked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no defrciences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> I <br /> I <br /> I <br /> Note below all deficiences 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 />