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ELAINE 1680 ROGERS AVENUE WELLHEA 11) INSPECTION CHECKLIST <br /> TECH SERVICES— SAN JOSE,CALIFORNIA 95112 <br /> (408)573-7771 FAX <br /> ClientC't <br /> (408)573-0555 PHONE <br /> w __ $o�� o A� _ _ -,_ — --- • . _ St! Addfe—s5 <br /> „ Techntctafl--B- ` <br /> Date c 1 o I oo <br /> I Lid on box? 6 Casing secure? 12 Water standing in wellbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut fever 12a Standingabove the to of Casing?P g 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 seal out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too tar above grade? 12c Water even with the top of casing? 10 Padlock present? <br /> 5 t_id seal intact? 10 Wellbox is too far below grade? 13 Well present? + <br /> �Pr 19 Padlock functional? <br /> 11 Wellbox is crushed/damaged? 14 Well cap found secure? <br /> 0 Check box If no deficiencies were found Note below deficiencies you were able to correct <br /> Well I D Deficiency I Corrective Action Taken <br /> L-11)64c <br /> a <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 /> r <br /> 4 <br />