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I l <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# 2.6q--7M4P—Z10$ Inspection date OL— <br /> _Site address 1 N• Qoz Sill �}t/E. Inspected by <br /> *— <br /> S7_utT�w CAI _ . BTS Event# Y 60 Z <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 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? 19 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 /> 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 /> Office review and assignments made by _ date oil <br /> ' <br /> Blaine Tech Services, Inc File WELLCHK s <br />