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M <br /> SHELL WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address wiK:7s� Ct,u�Lr- ejui, 1?�fva S c1C.e,n Date 7.) 3A <br /> Jots Number Ie)n7,c;>;. -_T- Q Technician Page _hof <br /> Z o E v <br /> 'w ¢ $ m u 2 LL o m Well Not New Previously <br /> It E — — Inspected Identified <br /> Deficiency <br /> Notes <br /> m tj �i m m 3 (enoles) In IIdenl fled Persists <br /> � <br /> Well ID <br /> Z <br /> w- X X <br /> X <br /> - $ <br /> - 5 <br /> Mw X <br /> AW-0 <br /> x <br /> - ► x <br /> - - -*Well box must-meet all three criteria to be compliant: 1) WELL IS SECURABLE BYDESIGN (12"orless) 2) WELL IS-MARKED WITH THE WORDS - --- <br /> "MONITORING WELL" (12"or less) 3) WELL TAG IS PRESENT, SECURE, AND CORRECT <br /> Notes: <br /> BIAINE TECH SERVICES, INC. SAN JOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE vH. M01nelechwal <br />