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WELL V 10 INSPECTION CHECKLIST AND REP/�ORDER <br /> Client 5 Site# Z� SZ ? � Inspection date '.. Y <br /> Site address 44,5- �. S Inspected by: c'i✓t" = <br /> BTS Event# <br /> 1. Lid on the box? Yes No &./Water standirig in the well box? 7. Can cap be pulled loose? <br /> �2. Lid whole? rt „ 5a. Standing above well top? 8. Can cap seal out water? <br /> 3. Lid secure?._ °'' 5b.R Standing below well tap? _ 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 /> Y .Check box if nddeficiences were found.- Note below deficiencies you were able to correct. } <br /> Well I.D. Deficiency Corrective Action Taken <br /> a ` <br /> -- Note below all deficiences that could not be corrected acid still need to.be corrected, <br /> w _ R I3T5 Office assigns or - Date Date <br /> �. Well I.D. Persisting Deficiency _ defers Correction to: assigned corrected w <br /> - r } <br /> i S <br /> Office review and assignments made by date <br /> Blaine Tech Services, lnc:'File,WELLCHK.s ` <br /> A <br />