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WELL DEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Site# Inspection date 6-10 q) <br /> Shell WIC#204-7524-2408 <br /> Site address 4445 N PERSHING AVE Inspected by 913 <br /> S TOC K70N <br /> BTS Event# 9 706te-�--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 Paalock present? <br /> 4 Lid seal intact? Sc 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 deficrences were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> I) <br /> !i <br /> I <br /> Note below all deflciences that could not be corrected and still need to be corrected <br /> STS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to: assigned corrected <br /> I <br /> r. <br /> Office review and assignments made by dale <br /> Blame Tech Services, Inc File WELLCHK s <br /> i <br />