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WELL H3 INSPECTION CHECKLIST AND REP#&ORDER <br /> Ins S��raj <br /> ClientSl/L� Site Inspection date <br /> Site address � � S' � /2 Inspected try- <br /> -�UrQ GlC7`Zsi� �' _ BTS Event# <br /> 1 Lid on the box? Yes No S. 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 deficrences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> f4w Z d IVELL © ` ICU <br /> w-1 94M0J Lf=- M <br /> fit/ 4-` INIFLC- <br /> LOCK rtro i AtW Z 3 5`7 !-0 <br /> Note below all deficlences 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 assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />