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SHELL WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address 2S75 c,v . -N (ik VII J T SucUaw•ecrl'a Date ` betho <br /> Job Number ► OU421 - b1 Technician Page ) of <br /> 0 <br /> Well Nol Pn:viuusly <br /> v 'tee E f v m Inspedetl New Identified <br /> > ' - 2m a a Deficiency Notes <br /> v m E '3 n tt ¢ (explain in Deficiency <br /> .0 ar °� a _ Idenllfied <br /> —` C <j v m notes) persists <br /> Well ID <br /> mlov ,C <br /> raw a X x <br /> Mw • N � Y K <br /> w • s , x Y <br /> pnta .� X Y <br /> Mtn • Q X �` X <br /> dt-rl.. , q ` � <br /> Mtea I / X X <br /> Mw • 12 � X <br /> Mw • 13 K x <br /> AlDvolf <br /> Mwrcd� I tc <br /> 'Well box must meet all three criteria to be compliant: 1 ) WELL IS SECURABLE BY DESIGN (12"or less) 2) WELL IS MARKED WITH THE WORDS <br /> "MONITORING WELL" (12"or less) 3) WELL TAG IS PRESENT, SECURE, AND CORRECT <br /> Notes: <br /> ELAINE TECH SERVICES, INC. SANJOSE SACRANIE14TO LOSANGELES SAN DIEGO SEATTLE MYwhlalletech.mra <br />