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I <br /> BLAINE 1680 ROGERS AVENUE WELLHEAD INSPECTION CHECKLIST <br /> SAN JOSE CALIFORNIA 95112 <br /> TECH SERVICES.s (408)573-7771 FAX Client ��_�V vii, <br /> (408)573-0555 PHONE <br /> Site Address 3 T� �/A1 <br /> = Technician .- <br /> �.� Date t i- ` _ CL `q <br /> 1 Lid on box? 6 Casing secure? 12- Water standing in wellbox? 15 Well cap functional? <br /> 2 Lid broken? 7 Casing cut level? 12a.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 rasing? 17 Can cap sed out water? <br /> 4 Lid bolts stripped? 9 Wellbox is too far above grade? 12a Water even with the top of casing? 18 Padlock present? <br /> 5 Lid seal intact? 10 Wellbox is too far below grade? 13 Well cap present? 19 Padlock functional? <br /> 11 Wellbox is aushedtdamaged? 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 Corrective Action Taken <br /> i <br /> Note below all defiencies that could not be Corrected and still need to be corrected <br /> STS Office assigns or Date Date <br /> Well I D Persisting Deficiency defers Correction to assigned corrected <br /> `ll(o b a l f <br /> fss� r <br /> Ar, 15 10 ICA, <br /> w`� e *,, a bti. <br />