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WELLHEAD INSPECTION CHECKLIST Page Z- of 7 <br /> Client Arc a5 Date 3l[(� :r <br /> Site Address M Qr j� G th o Ti c G9 <br /> Job Number 11839fa -3 c t Technician <br /> Well Inspected-� Water Bailed Wellbox Other Action Well Not <br /> No Corrective From Components Cao Lock Taken inspected Repair Order <br /> Action Required Well Cleaned Replaced Replaced explain (explain Submitted <br /> Well ID <br /> below) below <br /> MW-14B h` <br /> MINA 5A <br /> MW-15B <br /> MW-15C <br /> MW-16A <br /> MW-16B X <br /> MW-17A 3C <br /> MW-22A X <br /> MW-23A X <br /> MW-24A Jt <br /> MW-25A X <br /> MW-26A K <br /> MW-27A <br /> 11N-01 <br /> TW-02 <br /> TW-02B <br /> NOTES: AW-17A <br /> v <br /> SL INE TECH SERVICES,INC. SANJOSE SACRAMENTO LOSANGELES SAN DIEGO SEAMS waw.blainefeCh.com <br />