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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client r T Inspection date <br /> Shell 204-1752-1307 <br /> Site address 1267 COUNTRY CLUB <br /> STOCKTON Inspected by la•.S <br /> BTS !`vent# <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose? <br /> _2_=Lid_whole9 5a.-Standing-above=well to ? <br /> p 8—Can-cap <br /> 3 Lid secure2 sea!out water? <br /> 5b Standing below well top? 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6. Well cap/plug present? 11 Padlock functional? <br /> Check box if no detrcrences were found. Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> S-L S <br /> Note below all defclences 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 /> FT <br /> I <br /> I <br /> Office review and assignments made by date <br /> Blame Tech Services, Inc Fite WELLCHK s <br />