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WELL HEAD INSPECTION CHECKLIST AND REPAIR QRDEI=t <br /> Client 5 Site# ZG`r— 7 S Z y` 180C Inspection date: <br /> Site address Z 99LI Fre�y- S+,- Inspected by: ��'t <br /> BTS Event# 5 Z a0l9 T f <br /> i. 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. 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 /> 5. 1 Ida LC z 3T7 <br /> C� Q Ince:k Z <br /> Note below all defciences that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Weil I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. Fie WELLCHK.s <br /> J <br />