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BLAINE 1680 ROGERS AVENUE WELLHE Equ1va 98996183 ,CKLIST <br /> TECH SERVICES.w SAN JOSE CALIFORNIA 95112 wpLER1O0 <br /> (48)573-7771 FAX Client 4315 <br /> (4008)573-0555 PHONE SgOCKTON <br /> uT rF{!R 1+ <br /> Tawe�C Site Address <br /> Technician <br /> �T Date <br /> c <br /> 1 Lad on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well can functional? <br /> 2 lid broken? 7 Casing cut level? 12a Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lad bolts missing? 8 Debns in wellbox? 12b Standing below the top of casing? 17 Can can seal out water? <br /> 4 Lid bolts stripp 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Lad seal in 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well 10 Deficiency Corrective Action Taken <br /> Note below all defienc:es that could not be corrected and still need to be corrected <br /> BTS Office ass,cns or Date Date <br /> Well I D Persisting Defjc:ency defers Correction to assioned corrected <br /> II <br /> i � J <br /> I � 1 <br /> I <br />