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7— ! <br /> WER-L HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Shell WIC#204-7524-2408 - - - " - - - - Ir4ectron date: z <br /> Site address 4445 N. � E SONG AVInspected by:STOCKT <br /> BTS Event# <br /> 1. Lid an the box? Yes No 5. Water standing in the well box'7 7 Can cap be pulled loose? <br /> 2- Lid whole? 5a.Standing above well tap? S. Can cap seal out waters <br /> 3. Vd secure? °sb. Standing below well top*7 9. Padlock present? <br /> 4. Lid seal intake`? Sc Water even wdh top of well cap? 10. Padlock found locked? <br /> 6. Well(g4lug present? 11_ Padlock functional? <br /> Check box if no defrcrences were found. Note below defrpencies you were able to correct. <br /> Well I-D. Deflciency Corrective Action Taken <br /> I <br /> Note below aff defiaences that could not be corrected and_stil.need to be corrected- <br /> BTS <br /> orrectedBTS Office assigns or Date Date <br /> Well I.D. Pera sting Deficiency defers Correction to: asmgned corrected <br /> I <br /> S <br /> ------office renew,and assignments made by- date - - -- — <br /> Slaine Tech Services, Inc. Fie WELLCHKs <br /> s <br />