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- 7 — <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client ff Site# ZOY- 4 Inspection date_ 9---(A —q S <br /> Site address r J3 j we P7--ie- /9ne. Inspected by- � e <br /> STe�Kloiy ._ 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-M-Paolock-present?-- -Y <br /> 4. Lid seal intact? 5c Water even with top of well cap? 10 Padlock found lockea? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deficiences 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 deflclences_that could_not-be_corrected-and_still_needfo_be.corrected— --_--- <br /> BTS Office assigns or- -- - ~Date__—Dafe _�-- <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> i <br /> w I <br /> Office review and assignments made by date <br /> Rfninim rn.-T: C�nri�.e� In^ C1LAfEI 1 CMI NK <br />