Laserfiche WebLink
WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> - Inspection date /,//-r <br /> Client --- <br /> Shell 204-75244305 �% <br /> Site address b20 W CHARTER WAY Inspected by <br /> STOCKTON -- <br /> BTS Event # JJJ <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=S1andfng=above=weII top? S3 C-dncap 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 capiplug pfesent? 11 Padlock functional? <br /> $7Check box if no deficiences were found Note below defic:encies you were able to correct <br /> Well I D Defectency Corrective Action Taken <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 />