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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �f <br /> 1lff Sde# ZOq r-752-5_ D6VO Inspection date Site address I Q-I ( d Lwt,- ' iunt&w6 inspected by 12e136r' <br /> 5-� ".1 e-OA- BTS Event# <br /> g a-7zs-s2- <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 top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? Sc. Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/pfug present? 11 Padlock functional? <br /> © Check box if no defrcrences were found Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> Note below all deffciences 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 review and ass-gnments made by date • <br /> Blaine Tec:i Services, Inc Fle WELLGHK s <br />