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WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client U(,-/A Site# Inspection date <br /> Site address /9/ 0 Inspected by /^r <br /> BTS Event# <br /> =f_,d_on_the_box?Yes=No= 5.—Water standing in the-wefl box? 7=Can-cap be pulled 16ose2 <br /> 2. Lid whole? 5a. Standing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 15b. 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 /> S Weil cap/ping present? 11 Padlock functional? <br /> ffCheck box if no deffcrerrces were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> { <br /> I <br /> 1 <br /> !I <br /> i <br /> Note below all deficiences that coule not be corrected and strll need to be corrected <br /> BTS—Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> f <br /> i <br /> II <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WEIICHK s <br />