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r WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client`3NJFy-& Sde# Z4 5-Z d 691� Inspection date / / —/ 7--1� <br /> Site address 7 '7/0 L o w E� 5,4C, /4 D Inspected by_ LA4 � 0 6'Li�Plq <br /> _ �'TrcKTori/ Cry-_ BTS Event# '74/// 7 —Z-3 <br /> r- <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 sea[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 deficiences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> iu w ' S !2 �s+'�t ff ✓� v i <br /> ,tic w-3 S I i i <br /> Note below all deficiences 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 /> f� <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK s <br />