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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# Inspection date <br /> Site address Shell WIC#204-7525-0104 Inspected by 'Ak c'�Cd P <br /> 6131 PACIFIC AVE. <br /> STOCKTON BTS Event # Q�� �L <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 /> �K_C-heck box-if no defrcrences were found— -Note below deficiencies you were able to-correct- <br /> Well I D. Deficiency Corrective Action Taken <br /> 0 <br /> -- Note belaw al defidiences thet could r&te 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 /> } <br /> Blaine Tech Services, Inc t=ile WELLCHK s <br />