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WELLHEAD INSPECTION CHECKLIST Pageof� <br /> Client Date 3hre /(tt <br /> Site Address M4, 4,, 1- (® � sL 7'reoc,v, <br /> d <br /> Job Number t la'3{(,.- ,-j'c4 Technician 3c,e Low <br /> Well Inspected- Water Bailed "box Other Action Well Not <br /> No Corrective From Components Cap Lock Taken Inspected Repair Order <br /> Well ID Replaced Replaced (explain (explain Submitted <br /> Action Required Wellbox Cleaned below) below} <br /> PZ-09 X <br /> PZ-10 <br /> IGW-01 <br /> IGW-02 <br /> IGW-03 X <br /> IGW-04 X <br /> IGW-05 x <br /> IGW-06 <br /> IGW-07 )C <br /> IGW-08 <br /> IGW-09 y <br /> IGW-10 (` <br /> NOTES: <br /> BLAINE TECH SERVICES,INC. SANJOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE vwM.blaineted,Co. <br />