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r <br /> 1680 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> BLAINE SAN JOSE.CALIFORNIA 95112 �1 � <br /> TECH SERVICES.a (408)573-7771 FAX Client r�i �AI <br /> �Qw�k mho y {408}573-0555 PHONE <br /> Site Address, 79 lt4 <br /> Technician ` <br /> w <br /> Date_ <br /> 1 Lid on box? 6 Casing secures 12 Water standing in wellbox? 15 Well cap functional? <br /> 2 lad broken? 7 Casing cut level? 12a.Standing above the top of casing? 16 Can cap be pulled loose? <br /> 3 Lid bolts missing? 8 Debns in wellbox? 12b Standing below the top of casing? 17 Can cap seat out waters <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 Lid seal intact? 10 Wellbox is too far below grader 13 Well cap present's 19 Padlock functonal? <br /> 11 Wellbox is crushed/damaged? 114 Well rap found secure? <br /> Check box if no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Defictenc Corrective Action Taken <br /> Note below all defienctes 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 /> We(( n n -k <br /> t4,.j w -fa <br /> S r/ <br /> t55 ?T �f <br /> 1 <br />