Laserfiche WebLink
T T7T+ � v <br /> E 1860 ROG*AVENUE 'VVELL+�r' SPECTI+DN CRECKLIS'r <br /> BLAIN ,sAN J05E,CA! IFORNIR 95112 <br /> TECH sESVICES— {406)573-7771'FAX Client I <br /> nv (4013)573-0555 PHONE <br /> Q�> Sde Address Z2: (" V Icer;; ..hod; <br /> Technician 54 y <br /> 7 <br /> T Date Ir I -pl--fir. ' <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap fUnchonal7 <br /> 2 Lid broken? 7 Casing cut level? 122.Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lad bolts missing? a Debris in welfbox7 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Weffbox is too far above grade? 12c Water even with the top of easing? 19 Padlock present? <br /> 5 Lid seaf intact? 10 Wellbox is too far below grade? , - 13 Well cap present? w __ __ y 19 Padlock functional? i <br /> 11 Wellbox Is crushed/damaged? 14 Well cap found secure? <br /> 0 Check box it no deficiencies were found Note below deficiencies you were aide to correct , <br /> Well I D Deficiency Corrective Action Taken <br /> M V -2 af <br /> Note below all deflencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br /> I <br /> I <br /> I <br />