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r <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client_mea l Site# zo4 -7-2-4 z koa Inspection date <br /> Site address y,414s �-A tersh,T\5 t,k'Q- Inspected by- !RG <br /> —'4c.4.-Acxt Ct, _ BTS Event 4 <br /> 1 Lid on the box'? Yes No 5 Water stanesng in the well box? 7 Can cap be pulled loose? <br /> 2 L d whole? Sa Stana:ng attiove well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b. Stane:ng below well top? 9 Padlock present? <br /> 4 L:d seal intact? Sc Water even with top of well cap? 10 Padlock found locked? <br /> 6 Well cap'plug presents 11 Padlock functional? <br /> Check box ,f no defrcrences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> i <br /> Note oelow all deficiences that cculd nct be corrected and still need to be corrected <br /> STS Office assigns or Date Date <br /> Well I D. Persisting Deficiency defers Correction to: assigned corrected <br /> f <br /> i <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />