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11 <br /> BLAINE 1680 ROGERS AvEiiuE _ WELLHEAD INSPECTION CHECKLIST <br /> TECH SERVICES. SANJOSE,CALIFORNIA 95112 <br /> (408)573-7771 FAX Client v <br /> (408)573-0555 P14ONE <br /> A Site AddressS�- <br /> N Technician G� <br /> Ar a oa�+���c Date - I <br /> I Lid on box? 6 Casing secure? 12 Water standing in wellbox?2 Ltd broken? I5 Well cap funchonat? <br /> 7 Casing cut level? 12a Standing above the to of casn� 7 <br /> 3 Lid bolts missrno7 8 Debris in wellbox7 p g 1S Can cap be pulled loose-;12b Standing below the lop of casing? 17 Can cap seal out water 7 <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the to of p casrng7 IB Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock funchona]? <br /> III Wellbox is crushedldamaged? 14 Well cap found secure? <br /> 1tTCheck box if no deflclencies Were found- Note below deficienciesou were ere able to correct. <br /> Well I D Deficient Corrective Action Taken <br /> Note below ail defiencles that could not be corrected and still need to be corrected <br /> BTS Office asSlons or Dale Dale <br /> Well I D Persisting Deficiency defers Correction to asst ned corrected <br /> 1 <br /> I l <br /> i E � <br />