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4� <br /> N <br /> I <br /> f <br /> SHELL. WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address fvq �wVJ 0 7 � 04� Date <br /> I <br /> Job Number ® � 1Technician � • fovvviS _ Ayw Page of <br /> LLu a WeII <br /> y3t v m Em y n Nod New Pevioiusly <br /> m a fetl <br /> DerC1en`�m <br /> Notes <br /> (explain Deficiency <br /> Identifietl ntes) <br /> Persists <br /> Well ID 3 <br /> MNNW l ID <br /> 9J11n9 — )C <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 LOS ANGELES SAN DIEGO SEATTLE w0mbtalnetecheum <br />