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I { <br /> 1 11 <br /> BLAINS 3880 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> TECH SERVICES.4 SAH JOSE,CALIFORNIA M12 <br /> 12 <br /> (408)573-7771 FAXClient l� <br /> �r IHm (408)573-0555 PHONE <br /> ;� Site Address 2 <br /> r X 3m <br /> Technician I'I 04`V- <br /> �% Date {9 <br /> ''Aro <br /> 1 Lid on box? 6 Casing secure? 12 Water standing in wellbox7 15 Well cap lunctronai7 <br /> 2 Lid broken? 7 Casing cut level? 12a standing above the fop of casnig7 16 Can cap be pulled loose? <br /> 3 Lid baits mrssrnp7 8 Debris in wellbox7 12b Standing below the top of casing? 17 Can cap seal'out waleO <br /> 4 Ltd bolts stnpped 7 3 Wellbox is foo far above gr ade7 12c Water even wrth the fop of casing 7 18 Padlock present? <br /> 5 Lid seal intact? 10 Welfbox is too far b=low grade? 13 Well cap present? 19 r edfock lunchonaf 7 <br /> I 1 Wellbox is ciushedldamaged? 14 Well cap found secure? <br /> 0 Check box if no deficiencies were found Note below deficiencies you were able to Correct <br /> Well 1 D Deficiency Corrective Action Taken <br /> f tole below all'defiencfes (flat could not be corrected and still need to be corrected <br /> STS 01tice assions or Dsle Dale <br /> Well I�Dl Persisting Deficiency defers Correction to assraned corrected <br />