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} y <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client-s Site# Zo Lj ` 75'Z y /Sn cl Inspection date to <br /> Site address /Y/ NI 67 /D0,, � Inspected by S <br /> 5 s"UL4&P , S6: BTS Event# <br /> _i =Ltd onjhe_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 /> Q Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug presents 11 Padlock functional? <br /> EEI/check box if no deficiences were found Note below deficiencies you were able to correct <br /> Well LD Deficiency Corrective Action Taken <br /> I <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> BTS-Office-assigns or—Date—Dat <br /> Well I.D. Persisting Deficiency defers Correction to: assigned cormcted <br /> s <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK-s <br />