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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client - 4-7524-0808 Inspection date /It/6/75 <br /> Shy,. <br /> 7? <br /> Site address_SACRAMENTO Inspected by fi- <br /> STOCKTON <br /> - - - BTS Event# 98r1�v TL <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's 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's 10 Padlock found locked? <br /> 6 Well cap/plug present? 11 Padlock functional? <br /> Check box if no deficrences were found Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> i <br /> Note below all deficiencies that could not be corrected and SO need to be corrected <br /> BTS Office assigns or Date Date <br /> Weil I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and ass;gnments made by date • <br /> Blaine Tech Services, Inc File WELLCHK.s <br />