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i <br /> WELL HEAD INSPECT[Oty CHECKLIST AND REPAIR ORDER <br /> Client ( Srie# Y-?-�2( -CY6 V Inspection date <br /> S:te address ,3 Inspected by <br /> SL C _ _ BTS Event� �;1016) <br /> 1 Lid on the box? Yes No 5 Water stano:ng :n the well box? 7. Can cap be pulled loose? <br /> 2 Lid whole? 5a Stancing ab,--G e well top? 8. Can cap seal out water? <br /> 3 Lid securer 5b Standing be;o.v well top? 9. Paeiock present? <br /> 4 Lid seal intact? 5c Water even ti%rh top of well cap? 10. Padlock found locked? <br /> 6 Well capipl as present? 11. Paclock functional? <br /> Check box If no dehcfencas were found Nete below deficiencies you were able to correct <br /> Well I D Deficiency Correcfive .4ction Taken <br /> I I <br /> f <br /> ! I I <br /> 1 I <br /> 1 <br /> I I <br /> I I <br /> Note below all deuciences that could not be corrected and still need to be corrected <br /> 6TS Office assigns or Date Date <br /> Well I D. Persisting Deficiency cefers Correaion to assigned corrected <br /> Cj v d� <br /> i <br /> I I <br /> I I <br /> I I <br /> I <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />