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i v P <br /> BLAINS 1886 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> TECH SERVICES. SAN JOSE,CALIFORNIA 95112 <br /> (408)573-7771 FAX Client _y� — 75-2 ` <br /> V— / /'ir�_ A <br /> (408)573-0555 PHONE � --- <br /> za Site Address -2 -,6 Cs�4-J S <br /> Technician Sr, 0 Y <br /> Date _ .c"�2-10.1-a 42 <br /> o � <br /> 1 Lid on box? 16 Casmg secure? 12. Water standing in welibox? 15 Well cap Functional? <br /> 2 Lld broken? 7 Casing cut level? 12a-Standing above the lop of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox Is too far above grade? 12c.Water even with the top of rasing? 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 kxushedldamaged? 14 Well cap found secure? <br /> Of Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency Corrective Action Taken <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 assigned corrected <br />