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7 WELLHEAD �7 f r� <br /> �BLAII\IE 1680 HOGEno AVENUE WELLHEAD Ju-MEMON CHECKLIS 1 <br /> TECH S$EIVICES.a 5MIJOSE CALIFORNIA 95112 ` •� <br /> (409)57-3-7771 FAX Cllerlt_F$4014 ' <br /> (408)573-0555 PHONE <br /> Slte Address '7110 (�,ri <br /> 2 <br /> Technician `"1``�` '-f <br /> Date to r <br /> I <br /> 1 Ltd on box? 6 Casing secure? 12- Water standing in wellbox? 15 Well cap functtonal? <br /> 2 Ltd broken? 7 Casing cut level? 122.standmg above the top of casing? 16 Can rap be palled loose? <br /> 3 Lid bolts missing? 8 Debris in weilbox? 12b standing below the mp of casing? 17 Can cap seal outwater? <br /> 4 Ltd bolts stripped? 9 Weflbox is tDo far above grade? 12c Water even with the top of casmg7 18 Padlock present? <br /> 5 Ltd seal intact? 10 Welibox is Goo far below grade' t3 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 14 Well rap found secure? <br /> ECheck box if no deficiencies were found Note below deficiencies you were able to correct. <br /> Well I D Deficiency Corrective Action Taken <br /> I <br /> I <br /> Note below all defiencie5 that could not be corrected and still need to be corrected <br /> BTS Office assigns or Dale Date <br /> Well I D Persisting Defictenc defers Correclion to assigned corrected <br /> I <br /> I <br /> I <br />