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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER _ <br /> Client Site##2-0ZS2SDlp� Inspection date 1� <br /> Site address�1i� �Uf'__. _ Inspected by <br /> BTS Event# <br /> 1J-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-L-id seal intact?- - 5c.-Water even with top-of well cap?- 10 -Padlock-found <br /> locked?- <br /> 6 Well cap/plug present? J 1 I Padlock functional? <br /> Check box if no deficiences were found. Note befow deficiencies you were able to correct <br /> Well 1 D. Deficiency Corrective Action Taken <br /> / •/j r r <br /> !`l/LuVlee, �r <br /> I-j <br /> l <br /> Note-below all-deficiences that cold riot 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 /> Office review and assignments made by date <br /> 1 �' Blaine Tech Services, Inc. File WELLCHK s <br />