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I <br /> i <br /> SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN ) <br /> i <br /> Site Address Z5 7 ,S7" Cs "µt Date !b /2a loci <br /> I <br /> Job Number pRtoZ"t - ko i Technician K • besot! - &tta Page kof <br /> Z o E <br /> o o v Well Not Previously <br /> 6 41 w m m a — o. tospeclea oen ncy Identified Notes <br /> - P m E '5 m m 3 X (explain in Deficiency <br /> or 0Itl <br /> e — Uw n notes) onlifietl persists <br /> 0 U <br /> Well ID <br /> Nlw • 3 <br /> M 7( <br /> rtw .n t. <br /> NLw • � `' <br /> Awe lZ v <br /> M" t� ( 3 tnr�s sir, <br /> Mw . P .i <br /> htir . lt0 i,/ v <br /> tA \I,„ v <br /> M ✓ . ( Ij V ✓ <br /> Nkrd ,Ah v Dow%441" <br /> Ce LAAt( / <br /> W � x <br /> 0 - b X X <br /> CMN -66 )< X <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 /> BLAINE TECH SERVICES, INC. SANJOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE , .Wainelscn.com <br />