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t <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client _ �tl Site T_, Q �?gf4 -010 ) Inspection date <br /> Site addressInspected by <br /> BTS Event# <br /> 1 Lid on the box? Yes No 5 Water staneing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing zbo4e well top? 3 Can cap sea!out crater? <br /> 3 Lid secure? 5b Standing below%Nell fop? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even c,ith top of well cap? 10 Padlock found fockea? <br /> 16 Well capiplug present? i 1 Padlock functional? <br /> Check box if no defrcrences were fcund Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> C <br /> Mote 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 <br /> Blaine Tech Services, Inc. File WELLCHK s <br />