Laserfiche WebLink
I <br /> ISHELL WELLHEAD WSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN ) <br /> Site Address 16 1( ceuo ice-( iei we Date td • D <br /> Job Number ®yh?D1. 6x ( Technician Page ____L_of 2— <br /> v 4 79 <br /> a u o LL u 0 Well Not Previously <br /> v v m E m = n a o. Inspected New idenlified <br /> 3 W m C 3 c 3 ¢ o (explain in Deficiency Deficiency Notes <br /> — e = j� m m M _ notes) Identified persists <br /> ll ' U <br /> Well ID � 0 3 <br /> ,.. w • ? � F 11 <br /> r.! . 3 <br /> Mvt • '/ ✓I <br /> MW . 5� ✓ <br /> MvJ . b ✓ <br /> tAW • j V' <br /> MW $ <br /> MW q ✓r <br /> MwI • to 'i� <br /> MW t1 ✓1 <br /> IIAW X? / <br /> tAA • ( � <br /> tAW • 14 �✓ <br /> MW • i5 <br /> VMS 110 ooS ✓ <br /> tAw • 1 ? / <br /> pAW • 1$ <br /> "Weil hox 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 /> 31-AME TECH SERVICES, INC. SAN JOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE wwW.hlalnelechXoM <br />