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r <br /> n <br /> i <br /> WELLHEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# Inspection date /1 I l`r <br /> Shell W1C#204-7884-0501 <br /> Site address_ 3725 S.TRACY BLVD Inspected by <br /> TRACY <br /> BTS Event# c1�"�l« "�3 <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? Sc 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 defrclences were found Note below deficiencies you were able to correct <br /> Well i D. Deficiency Corrective Action Taken <br /> lnl c,J— <br /> I� <br /> _ f <br /> r <br /> Note 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 />