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7 <br /> WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client_ Shell WIC#204-7524.3505 Inspection date I-L ly <br /> 2575 couNTRY CLUB <br /> Site ad STOCKTON Inspected by--- L�_� <br /> -� BTS Event# 'cv"7 f Z 14• DI <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 with top of well cap? 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deticiences were found Note below deficiencies you were able to correct <br /> Well I D. Deficiency Corrective Action Taken <br /> • <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 />