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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# Zay - -7-szV` f s `9 Inspection date Y/Z/9 7 <br /> • / .J �G . 219. '7G <br /> Site address �`� �o Inspected by <br /> Sla c,C��rrJ C'9� BTS Event# 970 yaz -fi <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? Sc Water even with top of well cap? 10 Padlock found locked? <br /> 8 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 /> ticw -i 20 Cry✓ C r�.J"/„/C- y " Co 30 r <br /> Note below all deflclences 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 /> U�L✓� .CC'"J C��1/�C� <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />