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SHELL WELLHEAD NSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address 'l ,� COUNT2� CwB Date la • 1;jIm Df8 <br /> Job Number Technician J ��5S Page hof <br /> Z E <br /> v "U v e E o LL u Well Not Previously <br /> w a '�° E a n �- Inspected New Identified <br /> 0 m E 3 re m 3 rc of (explain in DldeNified Deficeficiency iency <br /> Notes <br /> tElf _ $ P u a v notes) Persists <br /> Well ID 3 3 N <br /> ¢W • I A `� � � F � (�rn113 Mesn ^-y <br /> � A �'C r15 <br /> �Op�bwlArl � <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, ING SAN JOSE SACRAMENTO LOSANGELES SAN DIEGO SEATTLE vmw.blainelech.com <br />