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I - <br /> r <br /> BLAINE680 ROGERS AVENUE i WELLHEAD INSPECTION CHECKLIST <br /> BLAINS SERVICES. SAN JOSE,CALIFORNIA 95112 <br /> TECH (408)573-7771 FAX ClientPaU%1V-A, <br /> (408)S73-0555 PHONE <br /> X40 <br /> ` Site Address- <br /> 3`7Z -> 5• T'Yct rA/ <br /> y <br /> Technician CPS <br /> N <br /> Date 2- <br /> i;ANb �Se� <br /> I Lid on box? 6 Casing secure? 12. Water standing in wellbox7 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? 8 Debris in welibox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox fs too far above grade? - 12c Water even will 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 crushedldamaged? 14 Well cap found secure? <br /> Check box If no deficiencies were found. Note below deficiencies you were able to correct <br /> Well 1 D. Deficiency Corrective Action Taken <br /> u <br /> l <br /> Note below all defiencles that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I D Persisting Deficiency _ defers Correction to. assigned corrected <br /> r <br />