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SHELL WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address 2575 tpuKJ j Gtuy 614 , Date 3MM o <br /> Job Number toaN7- t 'tWv I Technician X, �a , ;, .q � . Page Z of v <br /> Zo it <br /> g <br /> a < v o LLWell Not New Previously <br /> ur u m , is <br /> � a is n — Inspected Identified <br /> Deficiency <br /> m }' Notes <br /> 'u �i og E 5 y v or (explain in Deficiency <br /> — u = Lj $ a TI notes) Identified <br /> n <br /> Well ID 3 3 <br /> w•) `� X <br /> dos*cam )C <br /> tfarrs K J) <br /> Stuna�(h k X .J— <br /> "Well box must meet all three criteria to he 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 /> SIAINE TECH SERVICES, INC_ SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE viunv.elaineieU.com <br />