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1 <br /> M <br /> SHELL WELLHEAD INSPECTION FORM <br /> ( FOR SAMPLE TECHNICIAN ) <br /> Site Address 257 r $,, :j c-i , l„ ; IL-1 si ook " Date t1 <br /> Job Number ( io ixm tz,0l-- Technician K . b4emi t ,- r4t"N Page tof <br /> Z o E <br /> y Q w p 9 0 m Well Not New Previously <br /> v -. �° d o n a Inspected Identified Notes <br /> m o '5 d m X ¢ (explain in Dellclency Deficiency, <br /> — or `m Identified rtes) persists <br /> N K U <br /> Well ID s <br /> Nt � • a � <br /> ,u <br /> tv( w- t `d �% '� • <br /> tot t Y, <br /> W � tA q rr,tP�?" ttj (�4}GyY ) . L, r KA 4J tsi ;y1 <br /> `Well box must meet all three criteria to be compliant: 1 ) WELL IS SECURABLE BY DESIGN (1211 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 /> BLAWE TECH, SERVICES, INC. SANJOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE wrrw.blaineleN.com <br />