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ELAINE 1680 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> TECH SERVICES SAN JOSE,CALIFORNIA 95112 p <br /> (408)573-7771 FAX Client <br /> N� (408)573-0555 PHONE <br /> Site Address r 7 C v r J r—Ji.6 <br /> Technician Cc,)r r r' c Ar r- <br /> <, �C Da#e <br /> 1 Lid on box? 6 Sasing secure? 12 Water standing in wellbox? 15 Well cap functional?- <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the trop of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? S Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lad bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 114 Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> !2 -6 ho loch cite 6 j-01, erti revAcd ;WeAa .2357 /aGIZ <br /> 16-11 >•►c )ccl� cep l�ct fi.hJ,.�,,</ re(� l0crd 3c� f J 3 lee <br /> i <br /> Note below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Wc�elll I D Persisting Deficiency <br /> y defers Correction to assigned corrected <br /> C i'l?''f n f e 0�G FJ ee Cal j -�' f bct <br /> � I <br />