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a � 1 <br /> 1&811 R _AVENUE N ELLBEO SPECTION CHiCKLIST <br /> BLAINE SAN JOSE,CALIFORNIA 95112 <br /> TECH SERVICES. (408)573-7771 FAX ClientE _ <br /> (408)573-0555 PHONE ll <br /> Site Address 9!V6 lc�c -civ., Lb.4) <br /> Technician MXV6 S <br /> .1_ Date 6-O <br /> rc AMU <br /> 1 Lid on box? 6 Casing secure? 12_ Water standng in wellbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a Stenting above the top of casing 15 Can cap be pulled loose? <br /> 3 Ltd bolts missing? 8 Debris in wellbox? 12b Standing below the lap of rasing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 wellbox is too tar above grade? 12c Water even with the top of casino? 18 Padlock present? <br /> S Ltd seal infactl 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functionaf? <br /> 1 1 Wellbox is cushed/damaged? 14 Well cap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Dale <br /> Well I D Persistin❑ Deficiency defers Correction to assigned corrected <br /> ` f <br /> 1 <br />