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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> „ / <br /> Site Address 2 0"?, C Fre Date <br /> S.-pl n t f�—r �{ <br /> Job Number 09,4A�z*-2-' Technician -7- .S ,rbc Page <br /> z H o <br /> 0 <br /> m L a u u = o LL m Well Not New Previously <br /> U¢^ n Inspected IdenliFed Notes <br /> n o v' E ° m eficrenCY <br /> 2 (explain in Oltlen f d Deficiency <br /> 2 =y iJ y H p notes) Persists <br /> Well ID <br /> s - I <br /> s- Z <br /> s -z-gas ✓ V <br /> -S -3 <br /> d <br /> s- y <br /> X_ <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.INC. SAN JOSE SACRAMENTO LOS ANGELES SAID DIEGO SEATTLE wwu�.datrlelecRwm <br />