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1660 ROCKERS AVUIUE WEL AD INSPECTION CHECK-LUST <br /> BLAINE SANJOSF CALIFORNIA 95112 <br /> TECH sERVICES.ti (406}573-7774 FAX Client �/« A 4_ <br /> (408)573-0555 PHONE <br /> r°OJr �b <br /> 4 y Site Address Z O <br /> z i Technician <br /> Y <br /> �= Date <br /> It allo �ati <br /> 1 Ltd on box? 5 Casing secure? 12 Water standing in wellbox7 15 Well cap Itmctionaf' <br /> 2 Lid broken? 7 Casing cut level? 12a Standing above the top of castIT 2 16 Can cap be pulled loose? <br /> 3 Lid bolts missing-, 8 Debris in wellbox7 12b Standinu below the top of casino 7 17 Can t--p seal out water 7 <br /> Ltd bolts strippea" 9 Wellbox is too far above grade? 12C Water even rnth the top of castno7 16 Padlock present? <br /> 5 Lid seal intact? to Wellbox is too far below orade7 13 Well Cap present? 19 Padlock functional? <br /> 1 t Wellbox is crushedrdamaged? 14 Well cap found secure? <br /> I <br /> I <br /> 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 deftencies that could not be corrected and still need to be corrected <br /> BTS Office assions or Bale Dale <br /> Well I D Persisting Deficiency deters Correction to assoned corrected <br /> II <br /> f <br /> ' l <br />