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WELLHEAD INSPECTION CHECKLIST page of <br /> Client KtnGP Date gl Ig �r7 <br /> Site Address 4A P-eyegkt Stlrl- <br /> Job Number Technician <br /> Well Inspected- Water Bailed Wellbox Other Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Replaced Replaced <br /> Well ID Action Required Wellbox Cleaned explain explain Submitted <br /> below below <br /> •1 <br /> M�3 � <br /> M-6 X <br /> N- 10 n <br /> N• � X <br /> N•2`I x <br /> M.to T <br /> N <br /> 6-( 1� <br /> N-I�o <br /> N,l- <br /> NOTES: <br /> BLAINE TECH SERVICES.INC. SANJOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE www.blainelecb.wm <br />