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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER ` <br /> Client Site# Inspection date 2 TZ— <br /> Shell WIC#204-7524-aao8 • <br /> Site address_ 7910 LOWER SACAAMENTr Inspected by �+ <br /> STOCKTON <br /> BTS Event# Q�2� Z- <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled 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? 5c Water even wdh top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no def fences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all deflclences that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well 1.13 Persisting Deficiency defers Correction to assigned corrected <br /> F = IF 7 <br /> 0 <br /> Office review and assignments made by • <br /> date <br /> Blaine Tech Services Inc File WELLCHK s <br />