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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) s <br /> Site Address ? StS Alyy z bc' �n-';&J C� Date //3,0 ra <br /> Job Number t COV3c> -J t Technician o?, C a�t Page I of_'5 _ <br /> E p <br /> z `Nell Not Previously <br /> $ < v 444 u 3 Inspected Now Itlenllfietl <br /> n,2_' m m v m Deficiency Notes <br /> �i m E o m ¢ (explain fn Deficiency <br /> n n Iden tl0ed <br /> m m U � notes) Persists <br /> Well ID 3 3 <br /> i <br /> /k <br /> /It 'L. <br /> M AA3 <br /> X <br /> m X <br /> r X <br /> _7 <br /> MGJ -Iv X <br /> M,0-11 k <br /> -11 k <br /> mw- 13A k <br /> h <br /> Mw-It- <br /> -1� K <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 /> ELAINE TECH SERVICES,INC. SANJOSE SACRAMEMO LOS ANGELES SAN DIEGO SEATTLE vi+ev.�lelireted,cttn <br />