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• WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client wU(-;*T EW Sde# ,q 4'i <br /> Inspection date �--- L~�� <br /> Site address L-,�) E= to'Ttl Inspected by 1 <br /> T�t�7 BTS Event# - <br /> 9barZ`r- <br /> 1 Lid on the box? Yes No 5 Water stanamg in the well box? 7 Can cap be puffed loose? <br /> 2 Lid whole? 5a Standing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well fop? g 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 /> E] Check box if no defic,ences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> f <br /> f � <br /> f <br /> I <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 /> I <br /> Office review and assignments made by date <br /> Blame Tech Services, Inc File WELLCHK s <br />