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WELLHEAD INSPECTION CHECKLIST Page o�� <br /> Chen Date 2^ —d z <br /> Site Address <br /> Q � Ck. S v GSL. v� <br /> .fob Number nZ�Z 423 — WAS--.� Tgchnicfan �jIV1 tC S <br /> Well Impacted- Water Balled Wellbox Other Action Well Not <br /> No Corrective From components Cap Lock Taken Inspected Repair Order <br /> Viten ID Actlon Requtrad Wellbox Cleaned Replaced Replaced (explain (explain Submitted <br /> below) below <br /> "7— T <br /> INS W _ X <br /> w�S <br /> NOTES: <br /> ELAINE TECH SERVICES MM SAN JOSE SACAAMENM LOS ANOEMS SAN DEW www WFAnatarhtan <br /> i <br />