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a, J <br /> BLAINSImmomm 1880 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> TECH SERVICES SAN JOSE,CALIFORNIA 95112 �J <br /> (408)573-7771 FAX Client L — 15 Z <br /> (408)573-0555 PHONE } <br /> Site Address_. - 9_� �f>t.�.i!4 .K 9 C.14.�L_,• <br /> TechnicianCX n), 8 V <br /> Date .� f ,.._._, <br /> i <br /> 1 Lid on box? 6 Casing severe? 12 Water standing in wellbox? 15 Well rap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 0 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts strrpped7 3 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Ltd seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 1i Wellbox is c ushedldamaged7 14 Well cap found secure? <br /> O�Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> Nate below all defiencies that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well 1.1) Persisting Deficiency defers Correction to. assigned corrected <br />