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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site#�Q� -757Z S 0/4spection date <br /> Site address P C,4 :C= C_ Inspected by <br /> .5-to CA 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 /> 4-LUd-leaf intact? 5c.—Water even with top of-well cap?—10-Padlock-found locked?---L- <br /> 16 <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> _Check box ifi_no defrciences were found.-_-_Note below deficiencies you were able to correct _ <br /> Well I.D. Deficiency Corrective Action Taken <br /> i <br />�= ---� =Note=below=all-deficiences-that=could=not=be-corrected=and=still=need4o=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 />