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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER` <br /> Clientv2- Sde# �� SZ ��� Inspection date* f/ <br /> Site address .3/ iHG r,�-Q� Inspected by__��7 <br /> L D <br /> BTS Event# ��` ✓ <br /> 1 Lid on the box? Yes No 5 Water stand:ng in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? Sa Standing above well top? 18 Can cap seal out water? <br /> 3 Lid secure? 5b. Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? 5a. Water even with top of well cap? �10 Padlock found locked? <br /> 5 Well capiplug present? i 11 Padlock functional? <br /> Check box if no defrciences were founa Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> I <br /> Note below all deiiciences ►hat could not ce 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 /> Blaine Tech Services, Inc. File WELLCHK s <br />