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WELL HEAD INSPECTION CHECKLIST AND RI=P ORDER <br /> Client Sde#W OC-'0glnspection date- 111Z114--77 <br /> Site address 4 ��°� �rt/d /moi` .inspected by � i <br /> ! BTS Event#!Zz ,z <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/plug present? 11 Padlock functional? <br /> Check box if no defrciences were found. Note below deficiencies you were able to correct <br /> Well 1 D. Deficiency Corrective Action Taken <br /> • <br /> I <br /> Note below all deflciences that could not be corrected and st111 need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> i <br /> i <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />