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t <br /> -- WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Equiva 204-7524-3505 I Inspection date 5, <br /> `2575 COUNTRY CLUB <br /> STOCKTON _ Inspected by_M� <br /> BTS Event# gghA. <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose"' <br /> =-2---L,d=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"' 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 defivences were found. Note below deficiencies you were abbe to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> e*46 W IM A 23 5'I <br /> -------------------------- <br /> Note below all deficlences 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 <br /> date <br /> Blaine Tech Services, Inc File WELLCHK s <br />