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a <br /> BLAINS 1689 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> TECH SERVICES K SAN JOSE,CALIFORNIA 85112(408)573-7771 FAX Client <br /> (408)573-0555 PHONE <br /> 4.,;Q Site Address 143 S�ti <br /> b <br /> 1 Technician for ET <br /> Date j d C1 <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap lunctional7 <br /> 2 Lid broken? 7 Casing cut levet? 12a Standing above the tap of casing? 16 Can cap be pulled loose7 <br /> 3 Lid bolts missing? 8 Debns in wellbox7 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stnpped7 9 Welfbox is too far above grade? 12c Water even with the top of casing? i8 Padlock present? <br /> 5 Lid seal intact? 14 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushedldatnaged7 14 Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you Were able to correct <br /> Well I D Deficiency Corrective Action Taken <br /> i� <br /> Note below all defiencies 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. asst ned corrected <br /> r <br />