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i <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> SClient 2.0 Ll-Z,, ZZq -&Sde# Inspection date* S-1 '7 5' <br /> Site address LI`-]S 1 Al 6, tj U Ins ected b <br /> p Y <br /> 6'rDc-ce--r-b.N - - BTS Event# Q�pS IG --- <br /> 1 Lid on the box'2 Yes No S. 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? 5c. Water even wdh top of well cap? 10. Padlock found locked? <br /> 6. Well cap/plug present? 11. Padlock functional? <br /> Check box if no defrciences were found. Note below deficiencies you were able to correct. <br /> Well I D. Deficiency Corrective Action Taken <br /> 2� r <br /> Note below all deficiences that could not be corrected and stili 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 /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />