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SHELL WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address 2 S 7S �' c, ! /u� S fG� 1�� Date -11,_? r l'6 0 <br /> Job Number0 `7F7-j", l Technician e 1 Page of <br /> Z » E v v <br /> o LL o m Well Not Previously <br /> W_ n a a Inspected New Identified Notes <br /> mu — rc W (explain in Deficiency Deficiency <br /> a rn E $ rn v 3 '- voles) Identified persists <br /> - U Ute • -' tj <br /> Well IDcot/ rlw)et <br /> 3 <br /> a <br /> � w i k k vagi <br /> � . + <br /> ? of <br /> `Well hex 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 /> SUINETECH SERVICES, INC. SANJOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE wxw.blabrele[h.cam <br />