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c ' <br /> BLAINE 15817 90GERS AVENUE WELLHEAD INSPECTION CHECKLIS <br /> BL .SE�NiCES.� SAM JOSE CALIFORNIA 95112 <br /> (408)573 7771 FAX <br /> (40E)573 0555 r HOME <br /> 26-746' o l C Vb eft <br /> e'r A <br /> Site Address <br /> Z TechrncranAGOr..Y 1"f wrr� <br /> c <br /> y R <br /> .{T Date 4—Ior-0-0 <br /> 1 Lid cn box% 5 Casing secure' 12 Water standino in wpllbox7 15 Well cap Itinctional- <br /> 2 L=d broken 7 Casnrg cul le rel 12a Stcndtng above the top of casirio 7 15 Can cap by pulled loos,' <br /> z Lid bolts missino% A Debris in wellbox- 12b Stanoing below the top of casino% 17 Can C--p spar out w;31.t' <br /> 1 Ltd bolts stripped% 3 Weilbox is too far above grade' 12c Water elen with the top of casing' 18 Padlock pr¢senl' <br /> 5 Lid seaf intact% f0 Weilbex is too far blow grade' 13 Weir cap present' 14 Padiuck runrtlonal7 <br /> I 1 Wellbox is crushe6damacied7 I I Well cap found secure' <br /> EZ�rCheck box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well 1 D DefictericZ Corrective Action Taken <br /> Mole b-row all delrencies lbal could nol be corrected ana still reed to be corrpcted <br /> ET5 01lice assigns or male Dare <br /> Well 1 D Persisting Dellcienc� aerers Correctlon #o ass aped coiieciea <br /> I <br />