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BLAINS 1680 nOGEnS AVEt1UE WELLHEAD111SPECT.ION CHECKLIST' <br /> TECH SERVICES.• SANJOSE CALIFORNIA 25112 _��/Q�''**t�f A <br /> 1[408)573-7771 FAX Client I.L1G�14•• ` <br /> (408)573 0555 PHONE <br /> �4 <br /> ;� Stie Address 42 o c,+l. ,kt*1e1v%%n L!?, &�,d t- <br /> Technic= rdh M <br /> � � II <br /> rt�,� �►��t Date -Z E`tea <br /> I Lid on box 6 Casing semre' 12 Water standing rn welfbox? t5 Weft rap funchonal7 <br /> 2 Ind broken? 7 Casing cut level? 122 5tandina above the top of casina7 16 Can cap be pulled foose7 <br /> 3 Lid bolts mrssma 7 8 Debris In wpilbox 7 12b Starld'1ng b?low the hop of casino-, 17 Can cap seat out water 7 <br /> 4 Lid bafls stripped- a Weflbox is too lar above tirade 7 12c 'Nater even with the top of casino, 18 Fadlock presenr7 <br /> 5 Lid seal'rntad' 10 Wellbox is tad far below orade-) 13 Well cap present? 19 Padlock funcbonal7 <br /> PI Wellbox Is crushedldamaaed" 14 Well cap laund secure? <br /> Check box if no deficiencies were found Note befow deficiencies you Were able to correct <br /> Well 10 DeficiencK Corrective Action Taken <br /> i <br /> Note below all detlencies that could nor be corrected and still need 10 be corrected <br /> BTS Office asstons or Dale bale <br /> Well 1 0 Fetsislino Deficiency defers Correclictl to assrglled corrected <br />