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SHELL WELLHEAD INSPECTION FORM <br /> (FOR SAMPLE TECHNICIAN) <br /> Site Address 3, 2 S C. Date tc> <br /> Job Number !60. ;C . rL-) Technician_:57 Loi>Ca� Page__Z of d_ <br /> sLL <br /> Well Not Previously <br /> m Inspected New Identified <br /> m E 3 m ' ¢ o (explain in Oeflciency Deficiency Notes <br /> IY U h `v 2 notes) Identified Persists <br /> Well ID U <br /> X NO <br /> �Mwy" X rvo <br /> X <br /> -ZZ X <br /> zL; x <br /> M,W s <br /> -zc� X- <br /> X,X, <br /> k- <br /> _32A k <br /> J -3 X <br /> All yj _3q <br /> MW 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 /> BIAINE TECH SERVICES,INC. SAN JOSE SACRAMENTO LOS ANGELES SAN DIEGO SEATTLE v blsnelech.= <br />