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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE.TECHNICIAN) <br /> $ite Address t`kk <br /> Date t2. A,2i-10 <br /> Job Number lot). It, ' V,jer- Technician <br /> Page 4 Of. Z <br /> —----- <br /> z 2 a & <br /> o $ a $ x a Wefl Not Previously <br /> .—g& $ m I^spedNew <br /> I <br /> ad Deficien [candied <br /> g 3 rc rc (explain in IdeMifled Deficiency Notes <br /> Well ID <br /> 3 v notes) Persists <br /> M - <br /> w- � g <br /> tiaw -7 6 `� <br /> Wvi - <br /> vu - I R <br /> r""'- 12Cf) <br /> ► - 114 <br /> "Well box mus 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 /> e y <br /> 31-AME TECH SERVICES,INC. SAN JOSE <br /> SACRAMENTO IOSANGElES SAN DIEGO SEATTLE <br /> vnnv.bblaelech.Cwn <br />