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WELL HEAD INSPECTION CHECKLISTAND REPAIR ORDER <br /> Client SreInspection date: / /S <br /> • Sile address ?It CD �� —(Ztc/Z;vnr..'Ij Inspected by: ,lam <br /> BTS Event T,"r <br /> 1. Lid on the box? Yes No S !'Dater stanc,ng 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. SIanding below well top? 9. Padlock present? <br /> 4 Lid seal intact? Sc. Water Even with lop of well cap? 10. Padlock found locked? <br /> 6. Well caprpfug present? 11.Paolock 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 /> +1 <br /> I <br /> f 1 <br /> I � <br /> I � <br /> i r <br /> i <br /> Note below all deticiences that could nct be corrected and still need to bA ccrrected. <br /> BTS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> I <br /> ice review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK.s <br />