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ELAINE 1690 RC( AVENUE WELLHEAD] �PECTION CHECKLIST <br /> TECH SERVICES. SAN JOSE.CALIFORNIA 96112 J <br /> (408)573-7771 FAX Client Li 1 I <br /> (408)573-0535 PHONE C,/ <br /> Site AddressC �G�t a✓ 1,,,E S fe(�vy� <br /> Technician r i L <br /> N Z <br /> Date <br /> Nvro <br /> I Lid on box? 6 Casing seaire? 12. Water standing in wellbax 7 15 Well cap tunctonal7 <br /> 2 !id broken? 7 Casing cit level? 12a.Standing above the top of cas.ng7 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? a Oebns in wellbox7 12b Stanaina below the tap of casino 7 17 Can Cao seal out water? <br /> 4 Lid bolts stripped? g Wellbox is too Far above gide? 12c Water even with the top of casing? 18 Padlock presenr7 <br /> 5 Lid seal intacO 10 Wellbox is too far below orade7 13 Well cap presents 18 Padlock functonal7 <br /> 11 Weilbax is crushed/darnaaed? 14 Well caD found secure? <br /> 0 Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Dericienci Corrective Action Taken <br /> 5b 04- ye-eye-e W e f,6 <br /> i <br /> I <br /> II <br /> I <br /> Note below all deilencies that could not be correclea and stili need to be correctea <br /> i <br /> BTS Office asslons or Date Date <br /> Well 1 D Persistina Deflc.encv aeiers Correction to Jass.aned cc,rec,ed <br /> i <br /> I <br /> i I <br />