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r <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client �! Site# Z4� Z� 2--� 2�SInspection date f� �l • <br /> Site address 7 s - r� s�=�'�9/�U�_ Inspected by <br /> BTS Event# <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap bepulled 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 caplplug 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 /> of �-f St ! a J 3 f, � alts <br /> G[� <br /> • <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 dale <br /> Blaine Tech Services, Inc File WELLCHK s <br />