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+.101 <br /> SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address 7&j44 t rxH-e,.,1 Sr CFoc�4' Date C f aT [to <br /> Job Number to"?-I- Iat.e l Technician V Ali Page I Of <br /> Z a E <br /> a <br /> 9' $c 3 u � $ WeN Not Previously <br /> m `g 8 m y° m Inspected New Identified <br /> _'-. m E m m M of (explain n Deficiency Deficiency Notes <br /> 8 � w o notes) Itlentified Persists <br /> Well ID 3 <br /> 5-t Y x <br /> X x <br /> s x A <br /> s- z es x x <br /> s-3 Ey K <br /> S-q k x <br /> 5- 6 Y <br /> i <br /> 'Weil box must meet all three criteria to be compliant:1)WELL IS SECURABLE BY DESIGN(12"w 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 /> aIAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOS ANGELES SAN MEW SEATTLE xvAr.Namenecn<wn <br />