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T J <br /> ► WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Shell WIC#204-7524-1509 Inspection date: q00131--2-1 <br /> 141 N ELDORADO <br /> Site address STOCKTON _ _ Inspected by• <br /> BTS Event - 910131-Z, <br /> 1 Lid on the box? Yes NO 5 1'Va'er stancsng in the well box? 7. Can cep be pulled loose? <br /> 2 Lid whole? 5a Stanoing above well top? 8 Can cap seal out water? <br /> 3 Lid secure? 5b. Standing be>o y well top? 9. Padlock present? <br /> 4 Lid seal intact? 5c Water even wrih top of well cap? 10 Paolock found loo'-eo? <br /> fi We!l caplpTug present? 11 Paclock functional? <br /> ❑ Check box if no deilclenc's T,ere fou d. No!e below def cienc,es you 1S ere ab,e fo correct <br /> Well I D. Deficiency I C,-rrective Action Taken <br /> u�►' i1 �� t SA ILG:D <br /> I! <br /> 1 I <br /> I <br /> I I <br /> i I <br /> I f <br /> ! I 1 <br /> I I <br /> Note bellcw all det,cfences that could net be corrected and still reed fo be corrected <br /> t BTS OL,ce assigns or Date Cafe <br /> Well I D. Persisting Deficiency defers Correction ►o: assigned corrected <br /> VE-w-t I ALL IIAve baokEfl wEiL, d- 1 <br /> Z I cAsid&-5 Wtztdt- Ir Dir- E01 i <br /> 3 I To APPLY cAP Fp ASI D <br /> I F�T- coulz�crty (� S <br /> I Buy I a <br /> IS/ s <br /> �— O© I <br /> I �� ./ I <br /> 015ce review and assignments made by date <br /> Blaine Tech Services, Inc. File WEL.LCHK s <br />