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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S-HEGL Site#?o 47 S 2 g dI o4 Inspection date-.11_-1"7, — <br /> . Site address 67 13/ P14-61 F!e 71 KF- Inspected by. L 14 ?7 T3 DL✓�/Z <br /> 57-00. 710s1/ , Z'A 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 fop? 8 Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <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 /> o 7 F,/,1le 71 ew>i ` Al F vv <br /> I <br /> {III I <br /> I <br /> i <br /> Note below all deficiences that could not 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 re"ew and assignments made by date <br /> Blaine Tech Services, Inc f=ile WELLCHK s <br />