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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client S0 FM Site# Zoe -7-5-Zit- Z-fVS Inspection date: //o L Y' <br /> Site address �4 S /f/�G Ave, Inspected by: 4-Aa e a1✓EX <br /> T4LKTa/>t L�- BTS Event# <br /> 1. Lid on the box? Yes No S. Water standing ,n 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 deficrences were found. Note below deficiencies you were able to correct. <br /> Well I.D. Deficiency Corrective Action Taken <br /> tA w-Z S Yds !e FIs a✓f wr -45e- <br /> Mw-3 .Sa <br /> Mw-( <br /> i <br /> Note below all deficences that could not be corrected and still need to be corrected. <br /> BTS Office assigns or Date Date <br /> Well E.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blame Tech Services, Inc. Fie WELLCHK s <br />