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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client Shell Wlc M4-7524-2408 Inspection date <br /> - -___-.- <br /> 4445 N.PERSHING AVE- <br /> Site <br /> YE ---- ___ _ ____ _ ___ _�__ _ _ _ _ _ • <br /> Site address STOCICTDIi Inspected by <br /> BTS Event# $—Z- <br /> 1 <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 presents <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 /> Check box if no deficrences were found Note below deficiencies you were able to correct <br /> Well I.D. Deficiency Corrective Action Taken <br /> • <br /> Note below all def�C�e�ces that could ^^} )n^ ^^rra^',sd and st►11 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 /> _ _ - Blaine Tech Services, Inc Fie WELLCHK.s <br />