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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Sde* 7-0 y_ y p r Inspection date - 9� <br /> Siteaddress ze"dinl, cic � inspected by <br /> BTS Event# <br /> 1 Lid on the box? Yes No 5 Water stanaing in the well box? 7 Can cap be pulled loose? <br /> 2 Lad whole? 5a. Standing above well top? 8 Can cap seal out water? <br /> 3 Lad secure? 5o Standing below well top? 9 Padlock present? <br /> 4 lad seal intact? 5c. Water even with top of well cap? 14 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deffcrences were found Note below defic:enc:es you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> lw-I I S 1 �� ���c <br /> 1 I <br /> I ! <br /> � � I <br /> I <br /> I <br /> II I I <br /> ! I <br /> Note below all deficiences that could not be corrected and Still need to be corrected <br /> BTS Otfim assigns or Date Date <br /> Well I.D. Persisting Defic:ency defers Correction to: assigned carrected <br /> I I <br /> I I I <br /> I <br /> I � I <br /> I � I <br /> � I f <br /> � I � <br /> I l I <br /> I I <br /> I I <br /> Office review and assignments made by <br /> date <br /> Blaine Tech Services, Inc Fie WEE L CHK s <br />