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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER fi <br /> Client Shell WIC#204-7884-0941 Inspection date a-21-41 <br /> 3725 S.TRACY BLVD. , •� <br /> Site address—' MACY Inspected by <br /> gqmnlp No. <br /> BTS Event# <br /> t � <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 /> B Well cap/plug present? 11 Padlock functional? <br /> Check box if no defrcrences 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 I D. Persisting Deficiency defers Correction to: assigned corrected , <br /> t <br /> s <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc. File WELLCHK s <br />