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i <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> i <br /> Client 43f4j!F-G`L Srte# ZD4 75-Z405,!:�a [nspection date 11 -17—q4 <br /> � I <br /> Site address? Y Inspected b L A f <br /> P � <br /> 5' TG'GrC'Tar�I CA- BTS Event# 941117 <br /> 1 L,d 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 defrcfences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> M w - S j2e t5- f 6 ✓Ep v,1A <br /> wt I"-3 S� . r ► t � <br /> Note below all deficcences that could not be corrected and strll 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 /> • <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />