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I' SMELL WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN) <br /> Site Address v7 S 7 5 (� ( y 1 T l t, /� . SSC c.rE-f c%._ Date '7Z? r, 119 <br /> Job Number (i' 9G7 f { - / Technician1. Ste / ��_ Page / of <br /> Z o E <br /> o �= u Well Not Previously <br /> a o .� m E m v a a c Inspected Now Identified <br /> Deficiency <br /> Notes <br /> v m E = M X (explain in Deficiency <br /> w tt = m 3 notes) Identified Pastels <br /> � Lj � N v <br /> Well ID 3 U <br /> n11L/- z k <br /> ,MW - 3 k k <br /> r 1 � �7 k k <br /> n, 1,,- c ,� k <br /> (/Av I f <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 /> BLAINETECH SERVICES, ING, SAN JOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE wuw.0lainelecn.com <br />