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BLAINE 1680 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST` <br /> TECH SEtaVICES+� SAN JOSE,CALIFORNIA 95112 <br /> (408)573-7771 FAX Client <br /> dim (408)573-0555 PHONE � + <br /> A Site Address �. �..c <br /> Technician V <br /> Date Z—"L G d - <br /> �Nb <br /> 1 Lid on box? 6 Casing secure? 112 Water standing in wellbox7 15 Well cap functional? <br /> 2.Lid broken? 7 casing cut level? 120.Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debris in wellbox? 12b Standing below the top of casing? 17 Can cap seat out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12c Water even with the top of casing? 18 Padlock present? <br /> 5 Ltd seal intact? 10 Wellbox is too far below grade? 113 Well cap present? 19 Padlock kmebonal? <br /> 11 Wegbox rs crushed/damaged? 14 Well kap found secure? <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 assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to. assigned corrected <br />